Persius/hicric huggingface dataset:
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the Guardant360 testing provided on December 7, 2019. 
 
You asked the Plan to pay for the Guardant360 testing. You say that you would like the plan to reconsider their 
denial. The Plan denied your request. The Plan says the services were billed incorrectly. 
 
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 Guardant360 testing is not supported in the medical record. Specifically, this service should be 
coded with code 81479. In addition, the appropriate DEX Z code identifier should be entered adjacent to the 
code in the comment/narrative field. Based on this information, we decided that Medicare rules for coverage of 
the Guardant360 testing have not been met. Therefore, we decided that the Plan does not have to pay for the 
Guardant360 testing provided on December 7, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for foot orthotics (L3000) provided March 7, 2020. 
 
You asked the Plan to pay for foot orthotics. You say that the foot inserts were medically necessary. The Plan 
denied your request. The Plan says this item is not a covered benefit. 
 
Medicare rules state that supportive devices for the feet (such as orthotics) are only covered for patients with 
diabetic foot disease or for patients who wear a leg brace. The Plan follows these same rules.   
 
Records show that the enrollee does not suffer from diabetic foot disease and does not wear a leg brace. 
Although orthotics may be appropriate for the enrollee, neither Medicare nor the Plan provides coverage of 
orthotics for the enrollee's condition. Therefore, we decided that the Plan does not have to pay for foot orthotics 
(L3000) provided March 7, 2020.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home health services provided to the enrollee. 
 
You asked the Plan to pay for home health services. You say that you would like the Plan to reconsider their 
denial of payment. The Plan denied your request. The Plan says the final claim did not have an appropriate Q 
code per Medicare guidelines. 
 
The Plan must follow Medicare rules. The rules say that certain data elements on the RAP and the claim must 
be completed for home health care services to be covered. 
 
We looked at the claim submitted, the file and the Medicare rules. Based on this information, we decided that 
Medicare rules for completing the claim for home health services have not been met. Specifically, the claim is 
missing an appropriate Q code per Medicare guidelines. Therefore, we decided that the Plan does not have to 
pay for the home health services provided to the enrollee.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services provided on January 2, 2020. 
 
You asked the Plan to pay for the laboratory 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 a covered benefit. 
 
The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few 
tests listed above, are not covered. 
 
The laboratory testing at issue in this appeal was requested solely for screening purposes. Medicare does not 
cover this test solely for screening purposes. Therefore, we decided that the Plan does not have to pay for the 
laboratory services provided on January 2, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an outpatient surgery and coinsurance for 
chemotherapy provided by a participating provider on May 6, 2020. 
 
You asked the Plan to waive the copayment for an outpatient surgery and coinsurance for chemotherapy. You 
say that you did not have these services. The Plan denied your request. The Plan says the correct cost-sharing 
amounts have 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 surgery and a 15% coinsurance for Medicare Part B prescription drugs.  
 
You have been asked to pay a $150 copayment for an outpatient surgery and a 15% coinsurance of the allowed 
amount for chemotherapy. The allowed amount is $46. The amount you are being asked to pay for 
chemotherapy is $6.90 ($46 x 15% = $6.90). The total amount you are being asked to pay is $156.90 ($150 + 
$6.90 = $156.90). Than outpatient surgery and chemotherapy falls within the outpatient surgery and 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 copayment and 
coinsurance for an outpatient surgery and chemotherapy provided by a participating provider on May 6, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for neurological services provided to the enrollee on January 21, 
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 payment for these services is included in the payment to the facility, and not separately 
reimbursable. 
 
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 denied CPT codes are not supported in the medical record. Specifically, the payment for the 
following codes are included in the payment to the facility: 
 
CPT 95861, CPT 95865, CPT 95927, CPT 95937, CPT 95938, CPT 95939.  
 
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 neurological services provided to the enrollee on 
January 21, 2020.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the nuclear medicine services provided on 
May 21, 2020. 
 
You asked the Plan to waive the copayment for the nuclear medicine services. You say that you feel you should 
not be responsible for this cost share amount and you would like the Plan to reconsider your request. The Plan 
denied your request. The Plan says you received nuclear medicine services on the date of service at issue in this 
appeal. The Plan says that the correct copayment has applied per your contract with the Plan. 
 
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 $510 
copayment for Nuclear Medicine Services.  
 
We looked at the file, the Plan's contract and Medicare rules. The file shows that you received nuclear medicine 
services on May 21, 2020. You have been asked to pay a $510 copayment for the nuclear medicine services. 
The nuclear medicine services fall within the Outpatient diagnostic tests 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 the nuclear medicine services provided on May 21, 2020.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) admission and services. 
 
You asked the Plan to pre-approve SNF services. You say that you cannot perform activities of daily living 
without assistance. The Plan denied your request. The Plan says you have no current skilled nursing or therapy 
needs. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors 
listed above are met. Custodial care is not covered. 
 
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 pre-approve SNF services. Our physician reviewer 
found that from a nursing perspective, you received oral medications, had stable vital signs, and were treated 
for pain. There are no identifiable skilled nursing service needs. Regarding rehab services, you are at a standby 
assist to contact guard assist with functional mobility. You require varying assist with activities of daily living. 
Although there are identifiable skilled therapy service needs, you do not require skilled nursing or therapy 
services on a daily basis. You do not meet severity of illness or intensity of service criteria for an inpatient 
basis in a SNF setting. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of SNF services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve skilled nursing facility (SNF) admission and services.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for Computed Tomography (CT) of the chest 
(71250) preformed. 
 
You asked the Plan to waive the copayment for the CT scan. You say that the copayment should be waived. 
The Plan denied your request. The Plan says the correct copayment 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 $110 
copayment for Diagnostic Radiology.  
 
You have been asked to pay a $110 copayment for the CT scan. The CT scan falls within the Diagnostic 
Radiology 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 Computed Tomography 
(CT) of the chest.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pay for physical therapy from an out-of-network provider at the in-
network rate. 
 
You asked the Plan to pay for physical therapy. You say that when you started therapy you didn't know that it 
was considered out-of-network. You say that it should be changed to in-network since this is the only place you 
can get therapy. The Plan denied your request. The Plan says the claims processed correctly. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information. Your 
contract with the Plan says that your deductible is $500 which applies to all items and services except those 
specifically excluded by the Plan's contract. Out-of-network services are not excluded from the deductible. 
Your contract with the Plan says that you must pay 50% coinsurance for physical therapy from an out-of-
network provider. 
 
The item or service you asked the Plan to pay for falls within the benefit category "Outpatient rehabilitation 
services". The Plan has followed Medicare rules by clearly disclosing in the contract that your $500 deductible 
applies to out-of-network services. Once the deductible is met you also must pay 50% coinsurance for physical 
therapy from an out-of-network provider.  
 
The records show that in-network providers were available. 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 pay for physical 
therapy from an out-of-network provider at the in-network rate.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the anesthesia services provided under 
code 00142-QX-P2-QS-22. 
 
You asked the Plan to pay for the anesthesia services. You say that you would like the Plan to reconsider their 
denial of payment. The Plan denied your request. The Plan says procedure code 00142-QX-P2-QS-22 was 
billed with either an invalid or missing modifier. The Medicare rule for payment of this claim has 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 and when necessary the required modifier. In this 
case, 00142-QX-P2-QS-22 was inappropriately billed based on the claim submitted and the medical record 
documentation. The plan states a corrected claim would be reviewed. Therefore, we decided that the Plan does 
not have to pay for the anesthesia services under code 00142-QX-P2-QS-22.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve physical therapy services to be provided by an out of 
network (OON) provider. 
 
You asked the Plan to pre-approve OON services. You say that a single provider clinic is able to offer 
continuity of care. The Plan denied your request. The Plan says a network gap does not exist. 
 
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 pre-approve care from out-of-network providers only in cases involving 
emergencies, out of area urgent care and care that cannot be provided by network providers. 
 
The requested provider in this case is not a network provider with the Plan. The Plan has network providers 
available who can provide the services at issue in this appeal. We found no exception that would require the 
Plan to pre-approve these OON services. Therefore, we decided that the Plan does not have to pre-approve 
physical therapy services to be provided 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 ureteroureterostomy services coded 50760 provided on 
July 22, 2019. 
 
You asked the Plan to pay for the ureteroureterostomy 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 50760 is ureteroureterostomy. 
 
We find that CPT code 50760 is not supported in the medical record. Specifically, the documentation supports 
that a ureteroneocystostomy was performed. There is a more appropriate code for this service performed. Based 
on this information, we decided that Medicare rules for coverage of the ureteroureterostomy services have not 
been met. Therefore, we decided that the Plan does not have to pay for the ureteroureterostomy services coded 
50760 provided on July 22, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for an injection of botulinumtoxina (Botox) 
provided on June 8, 2020. 
 
You asked the Plan to waive the coinsurance for Botox injection. You say that in the previous year the cost-
share for this service was lower. The Plan denied your request. The Plan says the coinsurance amount you are 
being charged is correct. The Plan also says that they have waived the $400 facility copayment for this claim, 
so you are only responsible for the $151.45 drug coinsurance. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay 20% 
coinsurance for in-network Botox injection. The allowed amount of this drug is $757.26, resulting in a 
coinsurance obligation of $151.45. 
 
You have been asked to pay 20% coinsurance for Botox injection. Botox injection falls within the Medicare 
Part B Prescription Drugs benefit category. This means that you have been asked to pay the correct amount 
based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you 
enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the coinsurance for an 
injection of botulinumtoxina (Botox) provided on June 8, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for outpatient hospital services provided on January 22, 2020. 
 
You asked the Plan to pay for the outpatient hospital 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 outpatient hospital services provided on January 22, 2020.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the skilled nursing facility (SNF) care 
provided from March 6, 2020 to March 31, 2020. 
 
You asked the Plan to waive the copayment for the SNF care. You say that you feel you should not be 
responsible for this cost share amount and you would like the Plan to reconsider your request. The Plan denied 
your request. The Plan says you received SNF care on the dates of service at issue in this appeal. The correct 
copayment has applied per your contract with the Plan. 
 
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 $0 
copayment per day for days 1-20 and a $178 copayment per day for days 21-100 for Skilled nursing facility 
(SNF) care 
 
We looked at the file, the Plan's contract and Medicare rules. The file shows that you received SNF care from 
March 6, 2020 to March 31, 2020. You have been asked to pay a $0 copayment per day for days 1-20, and a 
$178 copayment per day for days 21-41, totaling $3738. The SNF care falls within the Skilled nursing facility 
(SNF) care 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 the skilled nursing facility 
(SNF) care provided from March 6, 2020 to March 31, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission 
and services for the enrollee. 
 
You asked the Plan to pre-approve IRF care. You say that these services are medically necessary. The Plan 
denied your request. The Plan says that ongoing skilled services can be provided at a lower level of care. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described above. 
 
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 pre-approve IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. The 
patient is generally medically stable after a fall due to syncopal episode with no foal neuro deficits with no 
evidence of complex medical issues that require monitoring by an inpatient physical medicine and rehab 
physician three times per week or need for acute rehab nursing care. He still needs physical therapy to improve 
his mobility. While he may benefit from continuing physical therapy and occupational therapy, there is no 
evidence of need for an intensive therapy program with therapy 3 hours per day with frequent physician 
oversight and an interdisciplinary approach to rehabilitation care. Our physician reviewer found that the 
enrollee's condition does not meet Medicare criteria for IRF care. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services for the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Ipratropium bromide and Levalbuterol provided on May 
2, 2020. 
 
You asked the Plan to pre-approve Ipratropium bromide and Levalbuterol. You say that you would like the 
plan to reconsider their denial. The Plan denied your request. The Plan says the drugs received are not a 
covered benefit. 
 
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-
administered drugs. The self-administered drugs requested here are not among the types which are covered by 
Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve Ipratropium bromide and 
Levalbuterol provided on May 2, 2020.  
 
Benefits for Ipratropium bromide and Levalbuterol may be available under Medicare Part D. Contact the Plan 
that administers Part D benefits for further information concerning any benefits and appeal rights.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the rhythm ECG report (CPT code 93042) provided on 
March 10, 2020. 
 
You asked the Plan to pay for CPT code 93042. 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, we have confirmed that code CPT 
code 93042 has a bundled relationship with code 93227 and cannot be paid as billed. This code cannot be paid 
as a separate line item. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, 
we decided that the Plan does not have to pay for the rhythm ECG report (CPT code 93042) provided on March 
10, 2020.