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

 
We decided that the Plan does not have to pay for a home visit provided on February 10, 2020. 
 
You asked the Plan to pay for the home visit. 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 a home visit provided on February 10, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the medical services provided to the enrollee on March 1, 
2019. 
 
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 payment is not allowed for this claim because it was submitted after timely filing 
limitations. 
 
The Plan follows Medicare rules. The rules say that claims for services furnished on or after January 1, 2010 
must be filed no later than one calendar year after the date of service. 
 
The record shows that a claim for the medical services was not filed until April 14, 2020. This means that more 
than one calendar year from the date of service had passed before a claim was filed. Therefore, we decided that 
the Plan does not have to pay for the medical services provided to the enrollee on March 1, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the medical services provided on February 27, 2020 by an 
out of network (OON) provider. 
 
You asked the Plan to pay for the assisted living facility visit. You say that you rely on the assisted living 
facility to obtain needed authorizations. 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 February 27, 
2020 by an out of network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for comprehensive genomic profile (CGP) testing provided on 
April 6, 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 CGP testing must be billed with CPT code 81479 
for date of service April 6, 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 
comprehensive genomic profile (CGP) testing provided on April 6, 2020.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for comprehensive genomic profile testing provided on March 
18, 2020. 
 
You asked the Plan to pay for genetic testing. You say that this testing is covered by Medicare. 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 CGP testing must be billed with code 81479 for 
date of service March 18, 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 
comprehensive genomic profile testing provided on March 18, 2020.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the Guardant360 testing provided on April 16, 2020. 
 
You asked the Plan to pay for the testing. The Plan denied your request. The Plan says the services were billed 
incorrectly. 
 
The Plan must follow Medicare rules. Medicare rules say that Guardant360 testing must be reported with one 
unit of CPT 81479 and the appropriate DEX Z-Code.  
 
We looked at the file and Medicare rules. The requested Guardant360 testing was billed with multiple CPT 
codes. Per the applicable article, this testing must be reported with CPT 81479 and the appropriate DEX Z-
Code. Based on this information, we decided that Medicare rules for coverage of the testing have not been met. 
Therefore, we decided that the Plan does not have to pay for the Guardant360 testing provided on April 16, 
2020.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the Guardant360 testing provided on April 13, 2020. 
 
You asked the Plan to pay for the testing. The Plan denied your request. The Plan says the services were billed 
incorrectly. 
 
The Plan must follow Medicare rules. Medicare rules say that Guardant360 testing must be reported with one 
unit of CPT 81479 and the appropriate DEX Z-Code.  
 
We looked at the file and Medicare rules. The requested Guardant360 testing was billed with multiple CPT 
codes. Per the applicable article, this testing must be reported with CPT 81479 and the appropriate DEX Z-
Code. Based on this information, we decided that Medicare rules for coverage of the testing have not been met. 
 Therefore, we decided that the Plan does not have to pay for the Guardant360 testing provided on April 13, 
2020.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pay for subsequent nursing facility care, per day, for the evaluation 
and management of a patient (CPT Code 99309) provided on February 11, 2020. 
 
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 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 from 
January 7, 2020 through February 19, 2020. Therefore, we decided that the Plan does not have to pay for 
subsequent nursing facility care, per day, for the evaluation and management of a patient (CPT Code 99309) 
provided on February 11, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for syringe, sterile, 20 cc or greater, each (CPT Code A4213) 
and enteral formula, nutritionally complete with intact nutrients, includes proteins, fats, carbohydrates, vitamins 
and minerals, may include fiber, administered through an enteral feeding tube, 100 calories = 1 unit (CPT Code 
B4150) provided to the enrollee on December 24, 2019. 
 
You asked the Plan to pay for the DME. 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 DME have not been met. Healthcare Common Procedure 
Coding System (HCPCS) code B4150 (465 Units) remains not supported. The documentation submitted did not 
include an itemized shipping/billing invoice to indicate the specific supplies, or proof of delivery. Therefore, 
the billed supply code cannot be verified.  It is noted that multiple attempts were made to contact the provider 
for additional information.  
 
Healthcare Common Procedure Coding System (HCPCS) code A4213 (30 Units) remains not supported.  The 
documentation submitted did not include a valid physician order and an itemized shipping/billing invoice to 
indicate the specific supplies, or proof of delivery. Therefore, the billed supply code 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 syringe, sterile, 20 cc or greater, each (CPT Code A4213) and 
enteral formula, nutritionally complete with intact nutrients, includes proteins, fats, carbohydrates, vitamins and 
minerals, may include fiber, administered through an enteral feeding tube, 100 calories = 1 unit (CPT Code 
B4150) provided to the enrollee on December 24, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the treatment services provided from April 4, 2019 to June 
21, 2019. 
 
You asked the Plan to pay for the treatment services. You say that you would like the Plan to reconsider their 
denial of payment. The Plan denied your request. The Plan says the provider is ineligible to bill Medicare. 
 
The Plan must follow Medicare rules. The rules say no provider or supplier shall receive payment for services 
furnished to a Medicare beneficiary unless the provider or supplier is enrolled in the Medicare program. 
 
We looked at the file and Medicare rules. The file shows the treatment services were provided by a provider 
that has not enrolled in the Medicare program. Therefore, we decided that the Plan does not have to pay for the 
treatment services provided from April 4, 2019 to June 21, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for an oxygen concentrator provided from 
May 22, 2020 to June 21, 2020. 
 
You asked the Plan to waive the coinsurance for an oxygen concentrator. You say that you were advised that 
you would have full ownership of this equipment at this time. The Plan denied your request. The Plan says the 
coinsurance 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 20% 
coinsurance for Medicare-covered Durable Medical Equipment under the Basic Rx plan.  
 
The allowed amount for an oxygen concentrator was $70.39. Therefore, you have been asked to pay a $14.08 
coinsurance ($70.39 x 20% = $14.08). An oxygen concentrator falls within the Durable Medical Equipment 
(DME) and related 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 coinsurance for an oxygen 
concentrator provided from May 22, 2020 to June 21, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for implant removal (D6100) and placement of intra-socket 
biological dressing to aid in hemostasis or clot stabilization, per site (D7922) provided on March 12, 2020 by 
an out-of-network provider. 
 
You asked the Plan to pay for the dental services. You say that you are appealing for reconsideration of the 
denied charges. The Plan denied your request. The Plan says the services are not a covered benefit under the 
plan. 
 
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. The services are not listed in your EOC as a covered benefit; therefore, 
the services are not covered. Therefore, we decided that the Plan does not have to pay for implant removal 
(D6100) and placement of intra-socket biological dressing to aid in hemostasis or clot stabilization, per site 
(D7922) provided on March 12, 2020 by an out-of-network provider.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for Guardant360 testing provided on April 8, 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. 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 code 
81479 for date of service April 8, 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 8, 2020.
Appeal type: Lab
Decision: Unfavorable

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

 
We decided that the Plan does not have to pay for the medical services provided on October 9, 2019 by an out 
of network (OON) provider. 
 
You asked the Plan to pay for the domiciliary/rest home visit. You say that since the member was in a facility, 
the doctor was not responsible for getting authorization. The Plan denied your request. The Plan says these 
services were not authorized.  The assisted living facility where this patient resides is not a network provider 
and no authorization was requested.  The Plan says that 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 October 9, 2019 
by an out of network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the lab services provided on December 19, 2019 by an out of 
network (OON) provider. 
 
You asked the Plan to pay for the lab services. You say that these services do not require authorization. The 
Plan denied your request. The Plan says these services were not authorized. The plan also states that neither the 
provider of these services, nor the ordering provider, are contract providers with the plan. The plan states that 
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 lab services provided on December 19, 2019 
by an out of network (OON) provider.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pay for physician's services provided from July 22, 2019 to August 
5, 2019. 
 
You asked the Plan to pay for the physician's services. 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 physician's services provided from July 22, 2019 to August 5, 
2019.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the laboratory service (36415, 80048, 
84443, 85025) provided on November 29, 2019. 
 
You asked the Plan to waive the copayment. You say that you did not receive services from this provider. The 
Plan denied your request. The Plan says the copayment has been applied correctly to the service 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 $15 
copayment for each outpatient Medicare-covered laboratory test.  
 
You have been asked to pay a $15 copayment for the Medicare-covered laboratory test provided. 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 laboratory service (36415, 80048, 84443, 85025) provided on 
November 29, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the nursing home visit provided on March 19, 2020 by an out 
of network (OON) provider. 
 
You asked the Plan to pay for the nursing home visit. You say that the patient's medical group changed and this 
provider used to be a network provider. The Plan denied your request. The Plan says these out-of-network 
services were not authorized.  In addition, the nursing home where the services took place is not a plan facility. 
The plan says that 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. It is the provider's responsibility to confirm authorizations and insurance coverage prior to rendering 
services. 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 nursing home visit provided on March 19, 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 the medical services provided on November 13, 2019. 
 
You asked the Plan to pay for the medical services. You say that since the enrollee was in your nursing facility, 
the doctor was not responsible to get authorization. The Plan denied your request. The Plan says the provider is 
a non-network provider who does not work with the enrollee's health plan, and the nursing home, a non-
participating provider, referred the enrollee. The Plan states the enrollee's network primary care physician 
(PCP) did not refer for services. 
 
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 13, 
2019.