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

 
We decided that the Plan does not have to pay for the short-latency somatosensory evoked potential study, 
stimulation of any/all peripheral nerves or skin sites, recording from the central nervous system (95927) 
provided on February 26, 2020. 
 
You asked the Plan to pay for the short-latency somatosensory evoked potential study. The Plan denied your 
request. The Plan says the billed service was 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 95927 is short-latency somatosensory evoked potential 
study, stimulation of any/all peripheral nerves or skin sites, recording from the central nervous system; in the 
trunk or head. 
 
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 short-latency somatosensory evoked 
potential study. Our reviewer says that the service does not meet criteria. Our physician reviewer found the 
procedure report did not include short-latency somatosensory evoked potential study, stimulation of any/all 
peripheral nerves or skin sites, recording from the central nervous system; in the trunk or head was performed, 
and therefore cannot be verified that Medicare coverage criteria has been met. 
 
 
 
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 short-latency somatosensory evoked potential study have not been met. 
Therefore, we decided that the Plan does not have to pay for the short-latency somatosensory evoked potential 
study, stimulation of any/all peripheral nerves or skin sites, recording from the central nervous system (95927) 
provided on February 26, 2020.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for astigmatism-correcting laser surgery provided from February 
20, 2020 to March 5, 2020. 
 
You asked the Plan to pay for astigmatism-correcting laser surgery. You say that this provided you a medical 
benefit and should count towards your out-of-pocket maximum. The Plan denied your request. The Plan says 
this is not covered. 
 
Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine 
vision and eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in 
this case. The Plan does not cover laser surgeries. 
 
 
We looked at the file and the Plan's rules. The service at issue is excluded from coverage under the Plan's 
vision benefit. Because it is not a covered service, it does not count towards the maximum amount you pay for 
covered services. Based on this information, we decided that the Plan's rules for coverage of astigmatism-
correcting laser surgery have not been met. Therefore, we decided that the Plan does not have to pay for 
astigmatism-correcting laser surgery provided from February 20, 2020 to March 5, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided on July 8, 2019 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 and 
were performed in good faith. 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 services were rendered is 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 July 8, 2019 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 medical services provided on July 11, 2019 billed with 
codes 36248, 36248-76, 75774-26-59, and 75774-26-76-59. 
 
You asked the Plan to pay for the medical services as billed. You say that the records provided support that 
payment should be made. The Plan denied your request. The Plan says this claim billed using add-on codes 
without any valid primary codes. As such, it is not payable as billed. 
 
The Plan must follow Medicare rules. Medicare rules say that Type I add-on codes have a limited number of 
possible primary codes, which are published by CMS periodically. 
 
In this case, code 36248 is a Type I add-on code and its eligible primary codes are 36246 or 36247. Neither of 
these codes are billed on this claim meaning that neither line item with this code is payable. Code 75774 is a 
Type II add-on code. This means that there are not defined primary codes but it can only be paid when reported 
with an appropriate primary code. Although 36248 may have been an appropriate primary code for 75774, 
these codes are not payable and, as such, the add-on code is likewise non-payable. Therefore, we decided that 
the Plan does not have to pay for the medical services provided on July 11, 2019 billed with codes 36248, 
36248-76, 75774-26-59, and 75774-26-76-59.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for out of network physician services provided on February 24, 
2020. 
 
You asked the Plan to pay for this service. You say that these services should be covered by the Plan. The Plan 
denied your request. The Plan says you did not have prior authorization for out of network care. 
 
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 out of network physician services provided on February 24, 
2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for initial nursing facility care provided on December 24, 2019. 
 
You asked the Plan to pay for the initial nursing facility care. The Plan denied your request. The Plan says the 
Plan requires utilization of network providers when possible and available, and requires authorization for 
certain services. No medical necessity for an out-of-network provider, such as an urgent or emergency 
situation, has been documented. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The requested provider in this case and the referring provider are not network providers 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 initial nursing facility care provided on 
December 24, 2019.
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to pay for emergency care provided on June 25, 2018. 
 
You asked the Plan to pay for emergency care. You say that your primary insurance carrier has begun paying 
claims during this period, now it is time for the Plan to pay its portion. The Plan denied your request. The Plan 
says the denial of payment for this service is correct, because the Plan is the secondary payer for this claim and 
your primary insurance carrier must pay for this claim before it can be processed by the Plan. 
 
The Plan must follow Medicare rules. The rules state that Medicare plans are considered secondary insurers 
when an enrollee has another type of insurance. This means that the Plan is not responsible for paying for 
services until the claim for those services has gone to the primary insurer. However, plans are still required to 
coordinate their benefits with the primary insurers. Plans can coordinate their benefits with the primary insurers 
in three ways. First, the Plan can send the bill directly to the primary insurer for payment. Second, the Plan can 
direct the provider to send the bill to the primary insurer. Third, the Plan can pay for the services and submit a 
bill for reimbursement to the primary insurer. 
 
The Plan has met its obligation with regards to coordination of benefits. Specifically, the Plan has directed the 
provider to submit this claim to your primary insurance carrier. As the secondary insurer, the Plan cannot be 
held responsible for emergency care until the primary insurer has denied the claim for these services. 
Therefore, we decided that the Plan does not have to pay for emergency care provided on June 25, 2018.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a lumbar-sacral orthosis (L0650) provided to the enrollee on 
April 13, 2020. 
 
You asked the Plan to pay for the orthosis. You say that the claim should be paid. The Plan denied your 
request. The Plan says the documentation does not indicate services are necessary for treatment of the 
enrollee's condition. 
 
The rules say for Medicare to consider coverage and payment for any item or service, the information 
submitted by the supplier or provider must corroborate the documentation in the beneficiary's medical 
documentation and confirm that Medicare coverage criteria have been met. When conducting a review of a 
covered DME item, ordered by a physician, the contractor shall ensure that the physician saw the beneficiary 
and conducted a face-to-face assessment. Therefore, we decided that the Plan does not have to pay for a 
lumbar-sacral orthosis (L0650) provided to the enrollee on April 13, 2020.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for a CT scan provided on February 24, 2020. 
 
You asked the Plan to waive the copayment for a CT scan. You say that CT scans were always covered in the 
past. The Plan denied your request. The Plan says the claims were processed correctly and you are 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). Your contract with the Plan clearly says that you must pay a $250 
copayment for CT scans.  
 
You have been asked to pay the allowed amount of $116.93, which is less than the $250 copayment for a CT 
scan. A CT scan falls within the outpatient diagnostic tests and therapeutic services and supplies benefit 
category. This means that you have been asked to pay the correct amount based on your contract with the Plan. 
This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we 
decided that the Plan does not have to waive the copayment for a CT scan provided on February 24, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for comprehensive genomic profile testing provided April 14, 
2020. 
 
You asked the Plan to pay for the comprehensive genomic profile testing. You say that you are appealing the 
decision that Guardant360 test is experimental/investigational and request processing the claim in-network 
since Guardant is the only service provider for Guardant360. The Plan denied your request. The Plan says this 
service is not covered by Medicare or the plan 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We looked at the file, and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the comprehensive genomic profile testing have not been met. Therefore, we decided that the Plan 
does not have to pay for comprehensive genomic profile testing provided April 14, 2020.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for A PET Scan from the skull to thigh (78815-26, PS) provided 
on January 20, 2020. 
 
You asked the Plan to pay for the PET Scan. You say that you would like reconsideration based on the records 
submitted. The Plan denied your request. The Plan says this code was not reported with an appropriate 
diagnosis. 
 
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 78815-26, PS is not supported in the record. Specifically, the chapter 13 of the 
Medicare Claims Processing Manual includes a list of appropriate diagnosis codes for PET Scans for the initial 
treatment. Diagnosis code C50.919 is not included on this list.  Based on this information, we decided that 
Medicare rules for coverage of the PET Scan have not been met. Therefore, we decided that the Plan does not 
have to pay for A PET Scan from the skull to thigh (78815-26, PS) provided on January 20, 2020.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the removal of part of the small intestine (44121) provided 
on July 1, 2019. 
 
You asked the Plan to pay for the removal of part of the small intestine. You say that this was billed correctly. 
The Plan denied your request. The Plan says this code is not supported in the records. 
 
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 44121 is enterectomy, resection of small intestine; each 
additional resection and anastomosis (List separately in addition to code for primary procedure). The 
definitions of the other reported codes, 44160 and 44120, are colectomy, partial, with removal of terminal 
ileum with ileocolostomy and enterectomy, resection of small intestine; single resection and anastomosis 
respectively. 
 
We find that CPT code 44121 is not supported in the medical record. Specifically, the operative report 
documents only two resections of the small intestine. One is the removal of the ileum that is included in CPT 
44160, and the other was reported with 44120. The medical records do not include documentation of can 
additional resection of the small intestine, therefore, CPT 44121 cannot be verified. 
 
 
 
 
 
 
 
 
 
 
 
 Based on this information, we decided that Medicare rules for coverage of the removal of part of the small 
intestine have not been met. Therefore, we decided that the Plan does not have to pay for the removal of part of 
the small intestine (44121) provided on July 1, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 We decided that the Plan does not have to waive the coinsurance for an external defibrillator life vest provided 
by a participating provider on March 25, 2020. 
 
You asked the Plan to waive the coinsurance for durable medical equipment. You say that you only wore the 
vest for 30 minutes. The Plan denied your request. The Plan says the correct coinsurance 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 20% 
coinsurance for durable medical equipment.  
 
You have been asked to pay a 20% coinsurance of the allowed amount for durable medical equipment. The 
total allowed amount is $2,925.60. The total amount you are being asked to pay is $585.12 ($2,925.60 x 20% = 
$585.12). Since a life vest was provided, the correct coinsurance has been applied. Durable medical equipment 
falls within the durable medical equipment 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 an external defibrillator life vest provided by a participating provider on March 25, 2020.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for a PET scan and a Medicare Part B drug 
provided on January 28, 2020. 
 
You asked the Plan to waive the coinsurance for a PET scan and a Medicare Part B drug. You say that you 
cannot afford the charges. The Plan denied your request. The Plan says the claims were processed correctly and 
you are 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). Your contract with the Plan clearly says that you must pay 20% 
coinsurance for PET scans and Medicare Part B prescription drugs.  
 
You received a PET scan and a Medicare Part B drug on January 28, 2020. The total allowed amount is 
$1,794.83 and 20% of that is $358.97.  
 
You have been asked to pay the total coinsurance amount of $258.97 for a PET scan and a Medicare Part B 
drug. A PET scan falls within the outpatient diagnostic tests and therapeutic services and supplies benefit 
category. A Medicare Part B drug falls within the Medicare Part B prescription drugs benefit category. This 
means that you have been asked to pay the correct amount based on your contract with the Plan. This cost 
sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that 
the Plan does not have to waive the coinsurance for a PET scan and a Medicare Part B drug provided on 
January 28, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for subsequent nursing facility care provided on December 31, 
2019. 
 
You asked the Plan to pay for the subsequent nursing facility care. 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 subsequent nursing facility care provided on December 31, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for skilled nursing facility (SNF) services provided from January 
10, 2020, to January 13, 2020. 
 
You asked the Plan to pay for the SNF services. The Plan denied your request. The Plan says the enrollee did 
not received SNF care on these dates. 
 
The Plan must follow Medicare rules. Medicare rules say that the information submitted by the supplier or 
provider must corroborate the documentation in the beneficiary's medical documentation and confirm that 
Medicare coverage criteria have been met.  
 
We looked at the file and Medicare rules. The records show that the enrollee was admitted to an acute care 
hospital from January 10, 2020, to January 13, 2020. As the enrollee was not receiving SNF care during this 
period, the requested SNF care is not payable. 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 
skilled nursing facility (SNF) services provided from January 10, 2020, to January 13, 2020.
Appeal type: Inpatient Hospital
Decision: Favorable

 
We decided that the Plan has to pay for the acute inpatient hospital care provided from  January 17, 2020 to 
January 18, 2020. 
 
You asked the Plan to pay for acute inpatient hospital care. You say that you were not presented with the 
enrollee's insurance information until he was discharged. The Plan denied your request. The Plan says that this 
was not authorized. 
 
The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor 
expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases, 
consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or 
more. 
 
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 acute inpatient hospital care. Our reviewer 
says that the documentation supports that the criteria for inpatient payment are met in this case. Our physician 
reviewer found the records show that the enrollee was sent tot the emergency room for evaluation on January 
17, 2020. He had decreased breath sounds in the right posterior lung fields and bilateral lower extremity 
edema.. He was admitted with respiratory failure. On January 19, 2020 he had increased respiratory distress. 
His case was discussed with a surgeon who recommended transfer to a higher level of care facility for chest 
tube insertion. The review has determined that the record did show that at the time of inpatient admission the 
admitting physician reasonably expected that the patient's necessary hospital care would span two midnights, 
however, his condition deteriorated and he was transferred to a facility that could provide a higher level of care. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of acute inpatient hospital care have been met. Therefore, we decided that the Plan 
has to pay for the acute inpatient hospital care provided from  January 17, 2020 to January 18, 2020.