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

We decided that the Plan does not have to pay for the immunohistochemistry or immunocytochemistry services coded 88342 and the consultation and report on referred slides prepared elsewhere services coded 88321 provided on March 26, 2020.

You asked the Plan to pay for the immunohistochemistry or immunocytochemistry services and the consultation and report on referred slides prepared elsewhere services. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the services billed are not separately payable.

The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. The rules state that providers may bill services with a -59 modifier if the service billed with the modifier indicates a distinct procedural service.  

The medical records provided do not show that the service billed with the -59 modifier is a distinct procedural service. Specifically, both codes 88321 and 88342 were billed with the 59 modifier but the documentation does not support that these services were a distinct procedural service. Based on this information, we decided that Medicare rules for coverage of services billed with a -59 modifier have not been met.

Providers must report services with the appropriate CPT code. In this case, we have confirmed that code 88342 for the immunohistochemistry or immunocytochemistry services has a bundled relationship with code 88321 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 immunohistochemistry or immunocytochemistry services coded 88342 and the consultation and report on referred slides prepared elsewhere services coded 88321 provided on March 26, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided on January 8, 2020 by an out of network (OON) provider.

You asked the Plan to pay for the medical services. You say that these services were medically necessary. 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 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 8, 2020 by an out of network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the tangential biopsy of a skin lesion (11102), office visit (99202), destruction of a premalignant lesion (17000) and destruction of additional premalignant lesions (17003) provided on March 10, 2020.

You asked the Plan to waive the copayment. You say that you are requesting a reconsideration of the Plan's denial for payment. The Plan denied your request. The Plan says the copayment has been applied correctly to the services provided.

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 $50 copayment for services provided by a specialty care physician. 

You have been asked to pay a $50 copayment for the services provided by a specialty care physician. 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 tangential biopsy of a skin lesion (11102), office visit (99202), destruction of a premalignant lesion (17000) and destruction of additional premalignant lesions (17003) provided on March 10, 2020.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the medical services provided on April 16, 2020 by an out of 
network (OON) provider. 
 
You asked the Plan to pay for the medical services. You say that these services were requested by the patient's 
facility and were medically necessary. 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. 
 
Neither the provider in this case nor the facility where the patient resides is 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 medical services 
provided on April 16, 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 hospital discharge day management; more than 30 minutes 
(CPT Code 99239) provided on December 20, 2019. 
 
You asked the Plan to pay for the service. You say that the claim should be paid. The Plan denied your request. 
The Plan says the services are not supported by the records. 
 
The Plan must follow Medicare rules. We looked at the file and Medicare rules. Based on this information, we 
decided that Medicare rules for coverage of the service have not been met. Current Procedural Terminology 
(CPT) code 99239 (1 Unit) remains not supported. The submitted discharge summary does not support hospital 
discharge day management of more than 30 minutes was performed. A documented duration of time of 31 
minutes or more is required to support this code. Therefore, the billed service cannot be verified. It is noted that 
multiple attempts were made to contact the provider for additional information. Therefore, we decided that the 
Plan does not have to pay for hospital discharge day management; more than 30 minutes (CPT Code 99239) 
provided on December 20, 2019.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services rendered on February 25, 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 procedure codes are not supported. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
We find that CPT codes 81225, 81226, 81227, 81230, 81231, 81240, 81241, 81328, 81335, 81355, 81232, 
81283, and 81408 are not supported in the medical record. Specifically, there are no records to support the 
billing of these codes for the date of service at issue. 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 laboratory services rendered on February 25, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the medical services provided on May 20, 2020 by an out of 
network (OON) provider. 
 
You asked the Plan to pay for the medical services. You say that the patient's assisted living facility arranged 
for these medically necessary services. 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. 
 
Neither the provider in this case nor the patient's assisted living facility is 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 medical services 
provided on May 20, 2020 by an out of network (OON) provider.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the fluoroscopic guidance rendered on January 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 procedure code 77002 is not supported. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
In this case, the CPT Code Manual definition of code 77002 is fluoroscopic guidance for needle placement (eg, 
biopsy, aspiration, injection, localization device) (List separately in addition to code for primary procedure). 
 
We find that CPT code 77002 is not supported in the medical record. Specifically, this is an add-on code and it 
was not billed with a required primary procedure code. 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 fluoroscopic guidance rendered on January 13, 2020.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the x-ray services coded 71045 provided on February 11, 
2020. 
 
You asked the Plan to pay for the x-ray services. You say that you would like the plan to reconsider their 
denial. The Plan denied your request. The Plan says the services billed are not separately payable. 
 
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 71045 
for the x-ray services has a bundled relationship with code 74022 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 x-ray services coded 71045 provided on 
February 11, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an ultrasound examination of the heart and 
an inpatient stay provided from February 24, 2020 to March 3, 2020. 
 
You asked the Plan to waive the copayment for an ultrasound examination of the heart and an inpatient stay. 
You say that you were not informed of changes in policy. 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 $235 
copayment for each covered diagnostic procedure or test at a network outpatient facility. Your contract with the 
Plan clearly also says that you must pay a $325 copayment per day, per admission, for days 1-6 for in-network 
covered hospital stays.  
 
You have been asked to pay a $235 copayment for an ultrasound examination of the heart provided on 
February 24, 2020. An ultrasound examination of the heart falls within the outpatient diagnostic tests and 
therapeutic services and supplies benefit category. You have also been asked to pay a $650 copayment for your 
two day inpatient stay from March 1, 2020 to March 3, 2020. An inpatient 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 ultrasound examination of the heart and an inpatient stay 
provided from February 24, 2020 to March 3, 2020.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the medical services provided on May 6, 2020 by an out of 
network (OON) provider. 
 
You asked the Plan to pay for the medical services. You say that these services were requested by the patient's 
facility and they were medically necessary. 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. 
 
Neither the provider in this case nor the nursing facility where the patient resides is 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 medical 
services provided on May 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 an annual well woman exam visit provided on January 28, 
2020 by an out of network (OON) provider. 
 
You asked the Plan to pay for specialist office visit. You say that this provider is in-network. The Plan denied 
your request. The Plan says prior authorization was not obtained. The Plan says that this provider is not in-
network. 
 
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 an annual well woman exam visit provided on 
January 28, 2020 by an out of network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the crown- 3/4 porcelain/ceramic (D2783) provided on 
February 18, 2020. 
 
You asked the Plan to pay for the crown- 3/4 porcelain/ceramic (D2783). You say that you understood that the 
crown was covered. You say that you didn't know certain crowns were covered and others weren't. The Plan 
denied your request. The Plan says the 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 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 the 
crown- 3/4 porcelain/ceramic (D2783) provided on February 18, 2020.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for radiologic examination, chest; single view (71045) provided 
April 5, 2020. 
 
You asked the Plan to pay for the radiologic examination. You say that the enrollee had multiple exams on this 
date of service. The attached reports to support the level of service. Please reconsider for processing. The Plan 
denied your request. The Plan says per review of the submitted documentation the services billed is not 
supported. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
In this case, the billing of code 71045 was submitted inappropriately due to the bundled relationship of services 
within the specialty group. This service has already been paid to another physician. This code can only be 
billed once per day. Based on Medicare billing guidelines, this claim cannot be paid as billed. Therefore, we 
decided that the Plan does not have to pay for radiologic examination, chest; single view (71045) provided 
April 5, 2020.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for the home health services provided on 
December 3, 2019. 
 
You asked the Plan to waive the coinsurance for the home health services. You say that you did not need the 
services. The Plan denied your request. The Plan says you have been charged the coinsurance 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 30% 
coinsurance for Home Health Agency Care.  
 
You have been asked to pay 30% coinsurance for the home health services. The home health services falls 
within the Home Health Agency 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 coinsurance for 
the home health services provided on December 3, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for Guardant360 testing provided on April 13, 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's condition. The Plan denied your request. The Plan says the denial of payment for this testing is correct, because this testing was not billed with the appropriate coding.

The Plan must follow Medicare rules. Medicare rules say that Guardant360 testing must be billed with procedure code 81479 for date of service April 13, 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 Guardant360 testing provided on April 13, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for anesthesia for diagnostic or therapeutic nerve blocks and injections (01992) provided May 4, 2020.

You asked the Plan to pay for the anesthesia. You say that please reprocess this claim as in-network since the surgeon requested your service. The surgeon was paid and you are asking for the same since the claim was paid without authorization. The Plan denied your request. The Plan says the services were not medically necessary and therefore not covered.

The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered. 

We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pay for the anesthesia. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found that per LCD L34980, Local anesthesia or minimal conscious sedation may be appropriate. Use of moderate sedation and Monitored Anesthesia Care (MAC) is usually unnecessary. Documentation must clearly establish the need for such sedation in the specific patient. In this case, the documentation sent did not clearly establish the need for such sedation. The review has determined that the epidural steroid injection met the requirements listed in the LCD/PIM for Medicare coverage, however the use of monitored anesthesia care was not medically necessary for this enrollee.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the anesthesia have not been met. Therefore, we decided that the Plan does not have to pay for anesthesia for diagnostic or therapeutic nerve blocks and injections (01992) provided May 4, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the medical services provided on January 15, 2020 by an out 
of network (OON) provider. 
 
You asked the Plan to pay for the medical services. You say that the claim should be paid. The Plan denied 
your request. The Plan says the member sought non-emergent/urgent services on their own with a non-
contracting provider and did not allow the primary care physician (PCP) to request approval from the Health 
Plan which would have advised the enrollee where to seek the 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 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 15, 2020 
by an out of network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the Guardant360 testing provided on February 20, 2020. 
 
You asked the Plan to pay for the Guardant360 testing. You say that you would like the plan to reconsider their 
denial. The Plan denied your request. The Plan says the services were 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 Guardant360 testing is not supported in the medical record. Specifically, this service should be 
billed with code 81479. In addition, the appropriate DEX Z Code identifier should be entered adjacent to the 
code in the comment/narrative field. 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 the 
Guardant360 testing provided on February 20, 2020.