Persius/hicric huggingface dataset:
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the battery and charger your purchased for your power 
wheelchair on January 7, 2020 to January 26, 2020 from an out of network (OON) provider. 
 
You asked the Plan to pay for the battery and charger for your power wheelchair. You say that you were not 
aware that authorization was needed for these items. The Plan denied your request. The Plan says unauthorized 
items and services you get from non-plan providers are not covered. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The provider in this case is not a network provider with the Plan. The Plan had network providers available 
who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the 
items/services 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 battery and charger your purchased for your 
power wheelchair on January 7, 2020 to January 26, 2020 from 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 February 4, 2020 by an out 
of network (OON) provider. 
 
You asked the Plan to pay for the medical services. You say that your physicians rely on the patient's facility to 
obtain proper authorization. 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 of the services in this case nor the patient's assisted living facility 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 February 4, 2020 by an out of network (OON) provider.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for home visit for the evaluation and management of an 
established patient (CPT Code 99350) provided to the enrollee on September 30, 2019. 
 
You asked the Plan to pay for the services. You say that the claim should be paid. The Plan denied your 
request. The Plan says the Medicare rules have not been met. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
Based on this information, we decided that Medicare rules for coverage of the services have not been met. The 
enrollee was seen in their home on September 30, 2019 for a licensed vocational nurse (LVN) home care visit. 
According to Medicare, home services codes 99341-99350 are paid when they are billed to report evaluation 
and management services provided in a private residence. A home visit cannot be billed by a physician unless 
the physician (or advanced practitioner) was actually present in the beneficiary's home. Code 99350 is not 
supported by the medical records. Specifically, the medical records show the submitted services were 
performed by an LVN. The medical record is electronically signed by the LVN, and the non-participating 
physician who is billing the services signs the medical record via electronic DocuSign. There is no 
documentation that the physician was present during the home visit. Therefore, we decided that the Plan does 
not have to pay for home visit for the evaluation and management of an established patient (CPT Code 99350) 
provided to the enrollee on September 30, 2019.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for home visit for the evaluation and management of an 
established patient (CPT Code 99350) provided to the enrollee on July 19, 2019. 
 
You asked the Plan to pay for home visit for the evaluation and management of an established patient (CPT 
Code 99350) provided to the enrollee on July 19, 2019.. You say that the claim should be paid. The Plan denied 
your request. The Plan says the Medicare rules have not been met. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
Based on this information, we decided that Medicare rules for coverage of home visit for the evaluation and 
management of an established patient (CPT Code 99350) provided to the enrollee on July 19, 2019. have not 
been met. The enrollee was seen in their home on July 19, 2019 for a certified nursing assistant (CNA) home 
care visit. According to Medicare, home services codes 99341-99350 are paid when they are billed to report 
evaluation and management services provided in a private residence. A home visit cannot be billed by a 
physician unless the physician (or advanced practitioner) was actually present in the beneficiary's home. Code 
99350 is not supported by the medical records. Specifically, the medical records show the submitted services 
were performed by a CNA. The medical record is electronically signed by the CNA, and the non-participating 
physician who is billing the services signs the medical record via electronic DocuSign. There is no 
documentation that the physician was present during the home visit. Therefore, we decided that the Plan does 
not have to pay for home visit for the evaluation and management of an established patient (CPT Code 99350) 
provided to the enrollee on July 19, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the medical services provided to the enrollee from January 2, 
2020 through February 11, 2020. 
 
You asked the Plan to pay for the medical services. You say that the services were medically necessary. The 
Plan denied your request. The Plan says the provider is a non-network provider that does not work with the 
member's health plan, and the member was not referred by an in network provider. 
 
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 to the enrollee from 
January 2, 2020 through February 11, 2020.
Appeal type: Hospice
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the subsequent hospital care services provided on December 
13, 2019. 
 
You asked the Plan to pay for the subsequent hospital care services. You say that the enrollee's Hospice 
election was effective from December 13, 2019 to December 14, 2019. The Plan denied your request. The Plan 
says Original Medicare would be responsible for payment of all Medicare covered services related or unrelated 
to the enrollee's terminal condition. 
 
Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice 
services. Medicare hospice pays for claims related to the terminal illness. The rules say that the Plan may direct 
the provider to bill Medicare directly for these services.  
 
The enrollee was under the Medicare hospice benefit for the dates of service at issue in this appeal. Therefore, 
we decided that the Plan does not have to pay for the subsequent hospital care services provided on December 
13, 2019.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the medical services provided on November 20, 2019 by an 
out of network (OON) provider. 
 
You asked the Plan to pay for the medical services. You say that the services were medically necessary. The 
Plan denied your request. The Plan says this provider is a non-network provider who does not work with the 
member's health plan and the member was referred by their non-participating outpatient nursing 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 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 November 20, 
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 December 30, 2019 by an 
out of network (OON) provider. 
 
You asked the Plan to pay for the medical services. You say that you weren't aware that this provider was out 
of network with the enrollee's plan.  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 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 December 30, 
2019 by an out of network (OON) provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the special pump services rendered on March 4, 2020. 
 
You asked the Plan to pay for these services. You say that these services were medically necessary. The Plan 
denied your request. The Plan says that this is a non-covered services. 
 
The Plan must follow Medicare rules. The rules say that procedure codes with a status indicator of X are 
statutorily excluded.  
 
The provider submitted a claim for procedure code 99190 (special pump services). This code has a status 
indicator of X and no separate Medicare payment. Payment is included in the payment to the facility. 
Therefore, we decided that the Plan does not have to pay for the special pump services rendered on March 4, 
2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home visit rendered on August 7, 2019. 
 
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 99348 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 99348 is Level 2 home visit for the evaluation and 
management of established patient with problem of low to moderate severity, including expanded problem-
focused interval history and medical decision-making of low complexity, typical time with patient 25 minutes. 
 
We find that CPT code 99348 is not supported in the medical record. Specifically, the file shows that the 
services were rendered by an LVN and this provider type is not eligible to bill this 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 home visit rendered on August 7, 2019.
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 18, 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 Comprehensive Genomic Profile (CGP) testing (Guardant-360 and NEXT-Generation) 
requires use of CPT 81479. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
We find that the various denied CPT codes are not supported in the medical record. Specifically, the testing at 
issue in this case should be reported with CPT 81479. Based on this information, we decided that Medicare 
rules for coverage of the services have not been met. Therefore, we decided that the Plan does not have to pay 
for Comprehensive Genomic Profile (CGP) testing provided to the enrollee on March 18, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance charged for chiropractic care provided on 
October 16, 2019. 
 
You asked the Plan to waive this coinsurance. You say that you do not believe this is incorrect. The Plan 
denied your request. The Plan says the Plan contract states for general chiropractic care, you could pay either 
zero or up to 20% coinsurance for these services. 
 
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 you could have either zero or 20% 
coinsurance for general chiropractic care. 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 charged for chiropractic care 
provided on October 16, 2019.
Appeal type: ER
Decision: Favorable

 
We decided that the Plan has to pay for the electrocardiogram (93010) provided on April 20, 2020. 
 
You asked the Plan to pay for the electrocardiogram. You say that the member was seen in the emergency 
room and was treated and discharged by a different provider than who provided the electrocardiogram. The 
Plan denied your request. The Plan says that CPT code 93010 is a column II procedure to the column I 
procedure, 23650. 
 
The Plan must follow Medicare rules. Medicare rules say that MACs subject all line items for the same 
beneficiary, same NPI, and same date of service to NCCI edits.  
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the electrocardiogram have been met. Specifically, CPT code 93010 was rendered by a different 
provider with a separate provider than who rendered the column I code. Therefore, we decided that the Plan has 
to pay for the electrocardiogram (93010) provided on April 20, 2020.  
 
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again 
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake 
and/or send us the new information. This does not happen often. If we decide to open the case again, we will 
send you a letter.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the Guardant 360 panel provided on April 1, 2020. 
 
You asked the Plan to pay for the Guardant 360 panel. 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. 
 
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, Medicare guidelines say when billing for the Guardant360 molecular lab panel, procedure code 
81479 is the only code available for billing. Based on this information, we decided that Medicare rules for 
coverage of the Guardant 360 panel have not been met. Therefore, we decided that the Plan does not have to 
pay for the Guardant 360 panel provided on April 1, 2020.
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to waive the coinsurance for chiropractic service provided on October 17, 2019. 
 
You asked the Plan to waive the coinsurance for chiropractic service. You say that you were told that you 
would have no cost-sharing and do not understand why the Plan did not pay this amount. The Plan denied your 
request. The Plan says that the coinsurance amount 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 does not say in clear and accurate terms 
how much you should expect to pay for chiropractic services.  
 
We looked at your contract with the Plan. We did not see where the contract clearly says enrollees must pay 
20% coinsurance for chiropractic services. The Plan contract does not clearly say how much enrollees must pay 
for chiropractic services. This means that the Plan did not follow Medicare rules for disclosure of cost sharing 
information. Therefore, we decided that the Plan has to waive the coinsurance for chiropractic service provided 
on October 17, 2019.  
 
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again 
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake 
and/or send us the new information. This does not happen often. If we decide to open the case again, we will 
send you a letter.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the medical services provided in an assisted living facility on 
February 17, 2020 by an out of network (OON) provider. 
 
You asked the Plan to pay for the medical services. You say that this patient does not leave the facility for 
medical appointments due to their condition. 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 ordering provider 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 in an 
assisted living facility on February 17, 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 code 95868.  
 
You asked the Plan to pay for code 95868 which is needle electromyography; cranial nerve supplied muscles, 
bilateral, which you state was provided to the enrollee. You say that this claim should be paid. The Plan denied 
your request. The Plan says Medicare billing criteria are not met. 
 
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 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 code 95868. Our physician reviewer found based on the medical records provided, code 
95868 is not documented in the procedure report, and, therefore cannot be verified as performed.  We looked at 
this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules 
for coverage this code have not been met. Therefore, we decided that the Plan does not have to pay for 95868- 
Needle electromyography; cranial nerve supplied muscles, bilateral.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the Guardant 360 panel provided on April 21, 2020.

You asked the Plan to pay for the Guardant 360 panel. 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.

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, Medicare guidelines say when billing for the Guardant360 molecular lab panel, procedure code 81479 is the only code available for billing. Based on this information, we decided that Medicare rules for coverage of the Guardant 360 panel have not been met. Therefore, we decided that the Plan does not have to pay for the Guardant 360 panel provided on April 21, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the Comprehensive Genomic Profile (CGP) testing provided on April 28, 2020.

You asked the Plan to pay for the CGP testing. 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.

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 CGP testing have not been met. Therefore, we decided that the Plan does not have to pay for the Comprehensive Genomic Profile (CGP) testing provided on April 28, 2020.