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

We decided that the Plan does not have to pay for the CGP testing provided on January 27, 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 in order to report a CGP service, test providers 
should use CPT code 81479 at this time, in addition to the approved DEX Z-Code TM for the test. 
 
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 CGP 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 CGP testing provided on January 27, 2020.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a neurostimulator (63650). 
 
You asked the Plan to pre-approve the neurostimulator. You say that the spinal stimulator is medically 
necessary. The Plan denied your request. The Plan says rules for coverage have not been met. 
 
The Plan follows Medicare rules. Medicare rules say that before a neurostimulator can be implanted, a trial is 
required. 
 
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 neurostimulator. Our reviewer says 
that the stimulator is not medically necessary. Our physician reviewer found there is no documentation of a 
trial stimulator with results. Also, the enrollee has chronic back pain and more conservative measures can be 
tried. 
 
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 neurostimulator have not been met. Therefore, we decided that the Plan does 
not have to pre-approve a neurostimulator (63650).
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the ambulance services provided on July 
24, 2020. 
 
You asked the Plan to waive the copayment for the ambulance services. You say that you did not call for the 
ambulance and was not aware there would be a copayment. 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 $250 
copayment for each ambulance trip. You had one ambulance trip. The Plan charged you $250 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 provided on July 24, 
2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for circulating tumor cell (CTC) testing provided on January 10, 
2019. 
 
You asked the Plan to pay for CTC testing. You say that the Plan must cover this testing. The Plan denied your 
request. The Plan says the denial of payment for this testing is correct, because this testing is not covered by 
Medicare. 
 
The Plan must follow Medicare rules. Medicare rules say that CTC testing is not covered by Medicare for date 
of service January 10, 2019.  
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of CTC testing have not been met. Therefore, we decided that the Plan does not have to pay for 
circulating tumor cell (CTC) testing provided on January 10, 2019.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a skilled nursing stay provided by a 
participating provider from March 1, 2020, to April 26, 2020. 
 
You asked the Plan to waive the copayment for a skilled nursing stay. You say that you do not agree with these 
copayments. The Plan denied your request. The Plan says the correct copayment has been 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 $0 
copayment per day for days 1-20. There is a $178 copayment per day for days 21-100 for skilled nursing 
services/in-network.  
 
You have been asked to pay a $0 copayment per day for days 1-20. There is a $178 copayment per day for days 
21-100 for a skilled nursing stay. The total amount you are being asked to pay is $5,044.78 due to reaching 
your maximum out-of-pocket amount. A skilled nursing stay falls within the skilled nursing services/in-
network 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 a skilled nursing stay 
provided by a participating provider from March 1, 2020, to April 26, 2020.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayments for the two ultrasounds you had on January 
22, 2020. 
 
You asked the Plan to waive the copayments for the two ultrasounds. You say that you were not aware that the 
ultrasound would not be covered at 100%. The Plan denied your request. The Plan says you were charged these 
copayments 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 $110 
copayment for each Medicare-covered radiological diagnostic service (including ultrasounds).  
 
You have been asked to pay a $110 copayment for each of the two ultrasounds. This means that you have been 
asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual 
obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have 
to waive the copayments for the two ultrasounds you had on January 22, 2020.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for magnetic resonance angiography of the head (70544) 
provided on July 1, 2020. 
 
You asked the Plan to pay for magnetic resonance angiography of the head. You say that the enrollee had 
multiple tests on this date. The Plan denied your request. The Plan says the records do not show this was 
performed on the billed date of service. 
 
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 70544 is not supported in the medical record. this code was billed for date of service 
July 1, 2020, but the records support that this procedure was performed on July 2, 2020. Based on this 
information, we decided that Medicare rules for coverage of magnetic resonance angiography of the head have 
not been met. Therefore, we decided that the Plan does not have to pay for magnetic resonance angiography of 
the head (70544) provided on July 1, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to reimburse you for the total electric hospital bed purchased on 
February 6, 2020. 
 
You asked the Plan to reimburse you for the total electric hospital bed. You say that you would like the Plan to 
reimburse you for the total electric hospital bed. The Plan denied your request. The Plan says total electric 
hospital beds are not covered by Medicare or the Plan. 
 
The Plan must follow Medicare rules. Medicare rules say that a total electric hospital bed is not covered.  
 
While a total electric hospital bed may be appropriate in this case, neither the Plan nor Medicare offers 
coverage for this item. Therefore, we decided that the Plan does not have to reimburse you for the total electric 
hospital bed purchased on February 6, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to reimburse you for hearing aids provided on November 20, 2018. 
 
You asked the Plan to reimburse you for the hearing aids. The Plan denied your request. The Plan says the 
Plan's hearing aid provider does not accept claims for hearing aids purchased out-of-network and does not 
offer reimbursements for hearing aids purchased out-of-network. 
 
Medicare does not pay for hearing aids or related services. However, the Plan offers a hearing aid benefit that 
exceeds Medicare coverage. For that reason, the plan?s coverage rules apply in this case. The Plan pays for 
hearing aids only when purchased by the Plan?s hearing aid provider. 
 
We looked at the file and the Plan's rules. The file shows that the hearing aids were provided by an out-of-
network provider. Based on this information, we decided that the Plan's rules for coverage of the hearing aids 
have not been met. Therefore, we decided that the Plan does not have to reimburse you for hearing aids 
provided on November 20, 2018.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the skilled nursing facility (SNF) services provided to the 
enrollee from March 8, 2020, to April 16, 2020. 
 
You asked the Plan to pay for the SNF services. The Plan denied your request. The Plan says the enrollee no 
longer required skilled care. 
 
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 pay for the SNF services. Our reviewer says that 
daily skilled services are not necessary. Our physician reviewer found that the enrollee did not require skilled 
nursing services with  the specialized skill, knowledge and judgment of a skilled professional nurse required to 
safely and effectively provide medically necessary and reasonable treatment in a SNF during the dates in 
question. The enrollee did not have complex wound care or other ongoing SNF level skilled nursing needs 
during the dates in question. The enrollee's functional level with weight bearing limitations and periods of 
confusion did not require skilled therapy services with the specialized skill, knowledge and judgment of a 
qualified therapist to safely and effectively provide medically necessary and reasonable treatment only in a 
SNF. The enrollee did not require skilled nursing or skilled therapy services (or a combination of these 
services) on a "daily basis" in a SNF. As a practical matter, this enrollee did  not require the necessary services 
on an inpatient basis, in a skilled nursing facility setting during the dates in question. 
 
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 SNF services have not been met. Therefore, we decided that the Plan does 
not have to pay for the skilled nursing facility (SNF) services provided to the enrollee from March 8, 2020, to 
April 16, 2020.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for laboratory testing provided on September 25, 2019. 
 
You asked the Plan to pay for lab tests. You say that you have submitted supporting records. The Plan denied 
your request. The Plan says the denial of payment for these services is correct, because the documentation 
submitted does not include a valid physician order, lab requisition, or medical records stating exactly which 
tests were to be performed. 
 
The Plan must follow Medicare rules. Medicare rules say that a physician order or clear intent to order specific 
lab services is required for covered lab services.  
 
We looked at the file and Medicare rules. The documentation submitted does not include a physician order or 
clear intent to order the specific lab services billed on this claim. Based on this information, we decided that 
Medicare rules for coverage of lab tests have not been met. Therefore, we decided that the Plan does not have 
to pay for laboratory testing provided on September 25, 2019.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for radiology services (CPT 70450) provided to the enrollee on 
June 24, 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 a modifier indicating that this is separate and distinct service was not appended. 
 
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 the 
services has a bundled relationship with code 70450 and cannot be paid as billed. This code cannot be paid as a 
separate line item without the appropriate modifier. Based on the claim submitted, Medicare billing criteria 
have not been met. Therefore, we decided that the Plan does not have to pay for radiology services (CPT 
70450) provided to the enrollee on June 24, 2020.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pay for home visit services (CPT 99348) provided to the enrollee on 
July 29, 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 procedures must be performed with the appropriate CPT code that describes the services 
performed. 
 
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 99348 is "Level 2 established patient home visit." 
 
We asked our coding 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 services. Our reviewer says that the 
services at issue in this case were not supported by the medical records. Our coding reviewer found the home 
visit was performed by an LPN.  Documentation does not indicate that a Physician or other Qualified 
Healthcare provider was present in the home. In this case, an LPN is not a qualified healthcare professional, 
therefore this is not a billable service. 
 
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 services have not been met. Therefore, we decided that the Plan does not 
have to pay for home visit services (CPT 99348) provided to the enrollee on July 29, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the durable medical equipment (DME) (E1399), cable 
charger for a scooter, provided on May 22, 2020 by an out of network (OON) provider. 
 
You asked the Plan to pay for a cable charger for a scooter. You say that the service was medically necessary. 
The Plan denied your request. The Plan says you must use an in network provider for your services. If going 
out of network your provider must follow prior authorization requirements. The services were obtained from a 
non-Medicare health plan provider who is not under contract with the health 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. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of these services have not been met. Specifically, the record indicates that the provider at issue was 
not enrolled with Medicare for the date of service at issue. There was no documentation to verify the provider's 
enrollment in Medicare for the date of service at issue. Therefore, we decided that the Plan does not have to 
pay for the durable medical equipment (DME) (E1399), cable charger for a scooter, provided on May 22, 2020 
by an out of network (OON) provider.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for the services (CPT 37224) provided on April 1, 2020. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the maximum 
frequency for this code was exceeded. 
 
The Plan must follow Medicare rules. Medicare rules say that claims submitted where the unit of service 
exceeds the MUE value for the HCPCS/CPT code will be denied. 
 
In this case, the MUE for CPT code 37224 1. You billed 2 units of this code, exceeding the MUE. 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 (CPT 37224) provided on April 1, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the evaluation and management services provided on March 
27, 2020. 
 
You asked the Plan to pay for the services provided. You say that the medical records support the rendered 
services. The Plan denied your request. The Plan says the services were not performed for a separate diagnosis 
unrelated to the surgical procedure. 
 
The Plan must follow Medicare rules. Medicare rules say that the services included in the global surgical 
package include follow-up visits during the postoperative period of the surgery that are related to recovery 
from the surgery. 
 
In this case, the CPT Code Manual definition of code 99308 is subsequent nursing facility care, per day, for the 
evaluation and management of a patient. We find that the services at issue were provided within the global 
surgery period of a previous procedure. Evaluation and management services on the day of the procedure and 
during the 10-day postoperative period are not payable. Based on this information, we decided that Medicare 
rules for coverage have not been met. Therefore, we decided that the Plan does not have to pay for the 
evaluation and management services provided on March 27, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the services (CPT 88341) provided on May 13, 2020. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the services were 
billed incorrectly. 
 
The Plan must follow Medicare rules. Medicare rules say that an add-on code describes a service that can only 
be reported in addition to a primary procedure.  
 
We looked at the file and Medicare rules. CPT 88341 is an add-on code. This code was not reported with an 
appropriate primary procedure code as required by Medicare rules. 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 (CPT 88341) provided on May 13, 2020.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the knee x-ray you had at a radiologist's 
office on June 15, 2020. 
 
You asked the Plan to waive the copayment for the knee x-ray. You say that you received a letter from the Plan 
stating that services were covered in full through the end of the year. You say that since the Plan didn't clearly 
specify which services would be cost-free that you shouldn't have to pay a copayment. The Plan denied your 
request. The Plan says you were charged this copayment correctly.  The Plan sent you a letter stating that the 
only copayments being waived this year are for primary care visits, behavioral health visits, and telehealth 
visits. The Plan says that because the allowed amount for this service ($32.13) is less than the copayment, you 
are being charged the allowed 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). Your contract with the Plan clearly says that you must pay a $45 
copayment for diagnostic tests (including x-rays) at a specialist's office.  
 
You have been asked to pay a $45 copayment for the knee x-ray. The knee x-ray falls within the diagnostic 
tests at a specialist's office 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 knee x-
ray you had at a radiologist's office on June 15, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. You say that the services are necessary. The Plan denied your 
request. The Plan says based on the documentation provided, coverage criteria has not been met. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described above. 
 
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 IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found the complexity of your nursing, medical and rehabilitation needs do not require an 
acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. You do not require 
treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive 
rehabilitation therapy program. While the medical record does document a need for physical and occupational 
therapy, it does not document a need for an intensive rehabilitation program. There is not a reasonable 
expectation that you will be able to fully participate in and benefit from the intensive rehabilitation therapy 
program provided in an IRF. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.