Persius/hicric huggingface dataset:
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for critical care, evaluation and management of the critically ill or critically injured patient; first 30-74 minutes (CPT Code 99291) provided to the enrollee from October 28, 2019 through October 29, 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 services are not supported by 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.

Current Procedural Terminology (CPT) code 99291 (1 Unit) remains not supported. The documentation submitted did not support a critical care visit of 30-74 minutes was performed on the billed date of service. The documentation does not include the time spent providing this service; therefore, the billed Critical Care Evaluation and Management code cannot be verified. It is noted that multiple attempts were made to contact the provider for additional information.

Current Procedural Terminology (CPT) code 99291 (1 Unit) remains not supported. The documentation submitted did not support a critical care visit of 30-74 minutes was performed on the billed date of service. The documentation does not include the time spent providing this service; therefore, the billed Critical Care Evaluation and Management code cannot be verified. It is noted that multiple attempts were made to contact the provider for additional information. 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 critical care, evaluation and management of the critically ill or critically injured patient; first 30-74 minutes (CPT Code 99291) provided to the enrollee from October 28, 2019 through October 29, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided on December 3, 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 there was no valid authorization for the 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 December 3, 2019 by an out of network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

The rules say that plans must pay for a medical service or item if regular Medicare would pay for it in this case. You can find this rule at 42 Code of Federal Regulations (CFR) Section 422.101.

The rules say that providers must report services correctly. Procedures should be reported with the CPT code that describes the services performed. You can find this rule in the Medicare National Correct Coding Initiative Manual, Chapter I(A).

The rules say that Guardant360 analyzes tumor-derived cell-free DNA (also known as ctDNA) to detect somatic alterations that, in conjunction with standard clinical assessment, can guide treatment decisions in the following intended use population: patients with Stage IIIB/IV NSCLC. To report a Guardant360 service for NSCLC, please submit the following claim information:
-	Enter 1 unit of service (UOS)
-	Enter the appropriate DEX Z-Code identifier adjacent to the CPT code in the comment/narrative field for the Part B claim field/types
-	CPT/HCPCS Codes: 81479
You can find this rule in the Local Coverage Determination and Article for MolDX: Guardant360 Plasma-Based Comprehensive Genomic Profiling in Non-Small Cell Lung Cancer (NSCLC) L37649 and A57425 (eff prior to 05/14/20).

If you want to read these Medicare rules, you can go to this website www.medicareappeal.com.

The Plan contract says that the Plan covers items and services in accordance with Medicare rules.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayments for an aspiration and/or injection of large joint 
or joint capsule (20610) and a needle localization by X-ray (77002) or to waive the coinsurance for an injection 
of Triamcinolone acetonide (J3301) performed on May 11, 2020. 
 
You asked the Plan to waive the copayments for an aspiration and/or injection of large joint and a needle 
localization by X-ray, and to waive the coinsurance for an injection of Triamcinolone acetonide. You say that 
you have never before had to pay a similar price for these services. The Plan denied your request. The Plan 
says the correct cost-sharing was 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 $50 
copayment for each specialist visit for Medicare-covered services and a $60 copayment for Medicare-covered 
X-rays and ultrasounds. The Plan contract also clearly says that you must pay 20% coinsurance for Medicare-
covered Part B drugs.  
 
You have been asked to pay a total of $111.25, or a $50 copayment for an aspiration and/or injection of large 
joint, plus a $60 copayment for a needle localization by X-ray, plus $1.25 coinsurance, or 20% of the Plan-
allowed cost of $6.24, for an injection of Triamcinolone acetonide. An aspiration and/or injection of large joint 
and a needle localization by X-ray fall within the "Outpatient hospital services" benefit category. An injection 
of Triamcinolone acetonide 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 copayments for an aspiration and/or injection of large joint or joint capsule (20610) 
and a needle localization by X-ray (77002) or to waive the coinsurance for an injection of Triamcinolone 
acetonide (J3301) performed on May 11, 2020.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the medical services provided on December 19, 2019 by an 
out of network (OON) provider. 
 
You asked the Plan to pay for laboratory testing. You say that neither the enrollee nor ordering provider 
physically attended your facility, and you did not have information on the enrollee's insurance requirements, 
limitations, or conditions. The Plan denied your request. The Plan says the denial of payment for these services 
is correct, because this provider is out-of-network with the Plan and the ordering provider is also out-of-
network with the 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. 
 
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 19, 
2019 by an out of network (OON) provider.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a CT scan provided by a participating 
provider on February 24, 2020. 
 
You asked the Plan to waive the copayment for a CT scan. You say that you have to get this done twice every 
year. You say that this is $90 more than you have been paying. 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 $150 
copayment for outpatient diagnostic tests/radiological diagnostic service.  
 
You have been asked to pay $112.86 which is less than your copayment amount of $150 for a CT scan. The 
correct copayment has been applied to the CT scan that was provided. A CT scan falls within the outpatient 
diagnostic tests/radiological diagnostic service 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 by a participating provider on February 24, 2020.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ultrasound services coded 76536 provided on March 10, 
2020. 
 
You asked the Plan to pay for the ultrasound services. You say that you would like the plan to reconsider their 
denial. The Plan denied your request. The Plan says the services billed are not supported by the documentation. 
 
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 76536 is ultrasound, soft tissues of head and neck (eg, 
thyroid, parathyroid, parotid), real time with image documentation. 
 
We find that CPT code 76536 is not supported in the medical record. Specifically, the documentation submitted 
did not include documentation of ultrasound, soft tissues of head and neck, real time with image 
documentation. Based on this information, we decided that Medicare rules for coverage of the ultrasound 
services have not been met. Therefore, we decided that the Plan does not have to pay for the ultrasound 
services coded 76536 provided on March 10, 2020.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab work provided on January 14, 2020 by an out of network 
(OON) provider. 
 
You asked the Plan to pay for lab work. You say that you would like this claim reprocessed and approved for 
payment. The Plan denied your request. The Plan says prior authorization was not obtained. The Plan says that 
the member's primary care physician did not refer these 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 lab work provided on January 14, 2020 by an out 
of network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the electrocardiographic monitoring 
provided on May 1, 2020 and review provided on May 4, 2020. 
 
You asked the Plan to waive the copayment for the External electrocardiographic recording (93225) and 
External electrocardiographic review and interpretation by a physician or other qualified health care 
professional (93227). You say that you should not have a copayment. The Plan denied your request. The Plan 
says because the allowance was less than the copayments so you are only responsible for up to 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 $50 
copayment for Outpatient diagnostic tests and therapeutic services and $40 copayment for a 
Physician/Practitioner specialist office visit. 
 
You have been asked to pay $28.01, less than your copayment, for the diagnostic service and $29.59, less than 
your copayment, for a specialist office service. 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 
electrocardiographic monitoring provided on May 1, 2020 and review provided on May 4, 2020.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for Guardant360? molecular pathology genomic profiling 
provided to the enrollee on March 12, 2020. 
 
You asked the Plan to pay for the testing. You say that this should be paid for. The Plan denied your request. 
The Plan says Medicare requires use of CPT 81479 to report a Guardant360? molecular pathology genomic 
profiling for renal cancer. 
 
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 testing have not been met. Therefore, we decided that the Plan does not have to pay 
for Guardant360? molecular pathology genomic profiling provided to the enrollee on March 12, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the medical services provided on January 20, 2020 by an out 
of network (OON) provider. 
 
You asked the Plan to pay for the medical services. You say that since the enrollee was in a 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 January 20, 2020 
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 acute inpatient hospital care provided from November 
13, 2019 through November 18, 2019. 
 
You asked the Plan to pay for acute inpatient hospital care. You say that the stay was medically necessary. The 
Plan denied your request. The Plan says the stay is not medically necessary. 
 
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 does not support that the criteria for inpatient payment are met in this case. Our 
physician reviewer found based on the provided documentation, it appears that the patient was stabilizing and 
did not require an inpatient stay of more than two midnights, nor was there documentation of a need for this as 
the main purpose for prolonged stay was related to decisions with discharge placement. 
 
 
 
 
 
 
 
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 not been met. Therefore, we decided that the 
Plan does not have to pay for the acute inpatient hospital care provided from November 13, 2019 through 
November 18, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the medical services provided on June 5, 2020 by an out of 
network (OON) provider. 
 
You asked the Plan to pay for the medical services. You say that these services were medically necessary and 
were provided 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. 
 
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 
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 June 5, 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 July 8, 2019 by an out of 
network (OON) provider. 
 
You asked the Plan to pay for the medical services. You say that the provider depends on hospital staff to 
verify eligibility and to obtain prior authorization from the enrollee's insurance company. 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 enrollee self-directed 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 July 8, 2019 by 
an out of network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a shoulder-hand-wrist orthosis (L3960) provided to the 
enrollee on February 22, 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 Plan must follow Medicare rules. Medicare rules say that for eligible telehealth services, 
telecommunications systems substitute for an in-person encounter. Medicare enrollees are eligible for 
telehealth services only if they are presented from an authorized originating site located in either a county 
outside of a Metropolitan Statistical Area (MSA) or a rural Health Professional Shortage Area (HPSA) located 
in a rural census tract. 
  
 
 
 
 
 
 
 
A review of the file does not show that the telehealth service was provided in an authorized originating site. 
This means that the telehealth visit is not a covered service under the Medicare program and cannot substitute 
for an in-person encounter. Consequently, the items/services ordered following the noncovered visit are 
likewise noncovered. Therefore, we decided that the Plan does not have to pay for a shoulder-hand-wrist 
orthosis (L3960) provided to the enrollee on February 22, 2020.
Appeal type: Lab
Decision: Favorable

 
We decided that the Plan has to pay for the Comprehensive Genomic Profile (CGP) testing provided on 
October 3, 2019. 
 
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 that the CGP testing should be billed under CPT code 
81479. 
 
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and 
diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or 
payment. 
 
The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their 
decision to deny your request. The Plan states that the appellant is appealing the denial of payment for CPT 
code 81479 provided on October 3, 2019. However, the Plan is denying payment for the CGP testing stating 
the provider needs to submit a bill with CPT code 81479 for payment consideration. The Plan is not clear in the 
reasoning for their denial of payment as the Plan is denying payment for CPT code 81479, which is the code 
that was billed by the provider. Therefore, we decided that the Plan has to pay for the Comprehensive Genomic 
Profile (CGP) testing provided on October 3, 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.