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

 
We decided that the Plan does not have to pay for medical services provided on November 6, 2019. 
 
You asked the Plan to pay for the medical services. You say that these services were medically necessary. The 
Plan denied your request. The Plan says unauthorized, non-plan care is not covered by the plan.  The plan also 
says that the patient's stay in the nursing facility was not authorized, and no affiliated services were authorized. 
 
The Plan must follow Medicare rules. The rules say that except for emergency and urgently needed services, 
plans are not required to make payments for any services received by enrollees that are not provided directly by 
the Plan or through arrangements made by the Plan. 
 
The services at issue in this appeal were not provided in an emergency or urgent care situation. These services 
were not provided by the Plan or through arrangements with them. Therefore, we decided that the Plan does not 
have to pay for medical services provided on November 6, 2019.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for CPT code 73562 provided on July 29, 2019. 
 
You asked the Plan to pay for CPT code 73562. You say that you would like the Plan to reconsider their denial 
of payment. The Plan denied your request. The Plan says the medical records do not support the billing of CPT 
code 73562 
 
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 73562 is Radiologic examination, knee; 3 views. 
 
We find that CPT code 73562 is not supported in the medical record. Specifically, the medical records provided 
do not include an imaging report for an x-ray of the knee with 3 views. Based on this information, we decided 
that Medicare rules for coverage of CPT code 73562 have not been met. Therefore, we decided that the Plan 
does not have to pay for CPT code 73562 provided on July 29, 2019.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the Comprehensive Genomic Profile (CGP) testing. 
 
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.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the Guardant 360 panel provided on April 13, 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 13, 2020.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the lab services provided on August 6, 2019 by an out of 
network (OON) provider. 
 
You asked the Plan to pay for the lab services. You say that these services were billed correctly and performed 
in accordance with the doctor's orders. 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 lab provider in this case nor the ordering provider is 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 lab services provided on 
August 6, 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 Comprehensive Genomic Profile (CGP) provided on July 
30, 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 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) provided on July 30, 2019.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the Guardant 360 panel provided on March 12, 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 March 12, 2020.
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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the assistant surgeon services rendered on February 21, 2020. 
 
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 the assistant surgeon services were not medically necessary. 
 
The Plan follows Medicare rules. Medicare rules say that items and services that are not medically necessary 
are not covered. Medicare rules say that for procedures with an assistant surgery indicator of 0, the payment 
restriction for assistants at surgery applies to this procedure unless supporting documentation is submitted to 
establish medical necessity. In this case, you billed assistant surgery services for CPT code 0569T and 0570T. 
The Medicare Fee Schedule Database contains a surgical indicator of 0 for this procedure.  
 
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 these services. Our reviewer says that the 
assistant surgeon services were not medically necessary. Our physician reviewer found the enrollee underwent 
transcatheter tricuspid repair. The billed procedure codes are not eligible for a co-surgeon. Although a co-
surgeon may be utilized to assist with these procedures, they generally do not require a co-surgeon and are not 
on the Medicare list of covered co-surgeon procedures. The records do not show that the services were 
reasonable or medically necessary. 
 
We looked at this physician's review, the file, and Medicare rules. 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 assistant surgeon services rendered on February 21, 2020.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services provided on September 12, 2019. 
 
You asked the Plan to pay for the laboratory services. 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 laboratory services have not been met. Therefore, we decided that the Plan does not 
have to pay for the laboratory services provided on September 12, 2019.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the Plasma-Based Comprehensive Genomic 
Profiling testing provided on March 16, 2020 billed with multiple line items of different CPT codes. 
 
You asked the Plan to pay for the testing as billed. You say that this should not be denied as 
experimental as this is a proven test which is supported for this patient. The Plan denied your request. The Plan 
says on review, it was found that no payment can be made for this testing because the provider is unbundling 
when there is a single CPT code which describes this testing. 
 
The Plan must follow Medicare rules. Medicare rules say that in order to report the testing, one 
unit of code 81479 should be reported with the appropriate DEX Z-code.  
 
As there is a single CPT code which describes this testing, the rule for coverage of this testing as billed have 
not been met. Therefore, we decided that the Plan does not have to pay for the Plasma-Based 
Comprehensive Genomic Profiling testing provided on March 16, 2020 billed with multiple line items of 
different CPT codes.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for home health services provided from January 5, 2020 to 
February 29, 2020 by a provider that is not enrolled in the Medicare program. 
 
You asked the Plan to pay for home health services. You say that this should be covered. The Plan denied your 
request. The Plan says these services were provided by a provider that is not certified for Medicare. 
 
The Plan must follow Medicare rules. Medicare rules say that 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 services at issue were provided by a provider that is not enrolled 
in the Medicare program. Based on this information, we decided that Medicare rules for coverage of home 
health services have not been met. Therefore, we decided that the Plan does not have to pay for home health 
services provided from January 5, 2020 to February 29, 2020 by a provider that is not enrolled in the Medicare 
program.
Appeal type: Transportation
Decision: Favorable

 
We decided that the Plan has to pay  ambulance transport provided to the enrollee on February 10, 2020. 
 
You asked the Plan to pay  this claim. You say that this claim was submitted previously and was processed 
with errors. You stated that the Plan did not process the original claim correctly and now its appearing to be a 
duplicate claim. The Plan denied your request stating this claim exceeds the allows units billed for this type of 
service.  
 
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 did not provide clear documentation that it attempted to 
correct its error on the processing for the original claim. The appeal communication clearly explains to the Plan 
the previous error and why a second claim was submitted. Therefore, we decided that the Plan has to pay  
ambulance transport provided to the enrollee on February 10, 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 Guardant360 Plasma-Based Comprehensive Genomic 
Profiling testing provided on October 9, 2019 billed with multiple line items of different CPT codes. 
 
You asked the Plan to pay for the Guardant 360 testing as billed. You say that this should not be denied as 
experimental as this is a proven test which is supported for this patient. The Plan denied your request. The Plan 
says on review, it was found that no payment can be made for this testing because the provider is unbundling 
when there is a single CPT code which describes this testing. 
 
The Plan must follow Medicare rules. Medicare rules say that in order to report the Guardant360 testing, one 
unit of code 81479 should be reported with the appropriate DEX Z-code.  
 
As there is a single CPT code which describes this testing, the rule for coverage of this testing as billed have 
not been met. Therefore, we decided that the Plan does not have to pay for the Guardant360 Plasma-Based 
Comprehensive Genomic Profiling testing provided on October 9, 2019 billed with multiple line items of 
different CPT codes.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the behavioral health services provided on May 5, 2020 by 
an out of network (OON) provider. 
 
You asked the Plan to pay for the behavioral health. You say that these services were requested by the patient's 
facility. 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 behavioral 
health services provided on May 5, 2020 by an out of network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services rendered on November 4, 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 82270 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 82270 is blood, occult, by peroxidase activity (eg, 
guaiac), qualitative; feces, consecutive collected specimens with single determination, for colorectal neoplasm 
screening (ie, patient was provided 3 cards or single triple card for consecutive collection). 
 
We find that CPT code 82270 is not supported in the medical record. Specifically, the documentation does not 
support that a fecal occult colorectal neoplasm screening was performed. 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 laboratory services rendered on November 4, 2019.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for molecular pathology genomic profiling 
provided to the enrollee on April 20, 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 Medicare requires use of CPT 81479 to report a molecular pathology genomic 
profiling for breast 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 services have not been met. Therefore, we decided that the Plan does not have to pay 
for molecular pathology genomic profiling provided to the enrollee on April 20, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the problem focused limited oral evaluation, crown, re-
cement or re-bond of a crown, and adjunctive procedures provided on January 31, 2019, February 19, 2019, 
March 06, 2019, April 10, 2019, April 30, 2019, July 31, 2019 and August 12, 2019 by an OON provider. 
 
You asked the Plan to pay for the problem focused limited oral evaluation, crown, re-cement or re-bond of a 
crown, and adjunctive procedures. You say that you and your agent called many dentists from the Plan's 
provider list, and were told that none of them accepted your insurance. The Plan denied your request. The Plan 
says crown, re-cement or re-bond of a crown, and adjunctive procedure are not covered benefits under your 
dental plan. The Plan also says that the problem focused limited oral evaluation was rendered by an OON 
provider, and benefits will only be released for this service when provided by an in-network dentist. 
 
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, crown, re-cement or re-bond of a 
crown, and unspecified adjunctive procedure are not among those covered under this benefit. The contract also 
clearly states that dental services that are rendered by an OON provider are not covered.  
 
 
Therefore, we decided that the Plan does not have to pay for the problem focused limited oral evaluation, 
crown, re-cement or re-bond of a crown, and adjunctive procedures provided on January 31, 2019, February 19, 
2019, March 06, 2019, April 10, 2019, April 30, 2019, July 31, 2019 and August 12, 2019 by an OON 
provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the physician services provided on March 26, 2020 by an out 
of network (OON) provider. 
 
You asked the Plan to pay for the physician services. You say that you would like the Plan to reconsider their 
denial of payment. The Plan denied your request. The Plan says the services provided were neither emergent 
nor urgent and prior authorization was not obtained to provide 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 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 physician services provided on March 26, 
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 perfusionist services provided on March 17, 2020. 
 
You asked the Plan to pay for the services provided. You say that the charges are for the perfusionist that setup 
and operated the heart-lung machine for this enrollee's surgery. The Plan denied your request. The Plan says 
services performed while an inpatient are included in the facility payment. 
 
The plan must follow Medicare rules. Medicare rules say that CMS does not pay any provider or supplier other 
than the facility for services furnished to a beneficiary. 
 
We looked at the file and Medicare rules. The facility must furnish all necessary covered services to the 
beneficiary either directly or under arrangements made with outside providers. This service was provided via 
arrangement of the facility. Payment for this service would have been included under the facility claim. 
Payment to you for this service is the responsibility of the facility. Based on this information, we decided that 
Medicare rules for coverage have not been met. Therefore, we decided that the Plan does not have to pay for 
the perfusionist services provided on March 17, 2020.