Persius/hicric huggingface dataset:
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 April 15, 2020 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 April 15, 2020 billed with multiple line items of different CPT codes.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the Guardant360 panel rendered on April 15, 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 claim was not billed correctly.

The Plan must follow Medicare rules. The rules say that the Guardant360 panel must be billed with procedure code 81479.

The file shows that the Guardant360 panel was not billed with code 81479 but as a panel of codes. 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 Guardant360 panel rendered on April 15, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the Guardant360 testing provided on April 21, 2020.

You asked the Plan to pay for the testing services. You say that the testing was ordered to determine if there was a more effective therapy to treat the enrollee's advanced cancer. The Plan denied your request. The Plan says there is a more appropriate code to describe the services provided.

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 looked at the file and the rules. The claim provided does not show that the Medicare coding and billing guidance has been followed. 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 Guardant360 testing provided on April 21, 2020.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for Guardant360 testing provided on April 4, 2020. 
 
You asked the Plan to pay for genetic tests. 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 Guardant360 testing must be billed with CPT 
code 81479 for date of service April 4, 2020.  
 
We looked at the file and Medicare rules. This testing was not billed with the appropriate code of 81479. Based 
on this information, we decided that Medicare rules for coverage of genetic tests have not been met. Therefore, 
we decided that the Plan does not have to pay for Guardant360 testing provided on April 4, 2020.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for ambulance services on April 19, 2020. 
 
You asked the Plan to pay for the ambulance services. You say that you were following safety 
recommendations for COVID-19. The Plan denied your request. The Plan says these services are not a covered 
benefit. 
 
The Plan must follow Medicare rules. The rules say that Medicare does not pay for ambulance services when 
there is no transport.  
 
The ambulance company did not provide transport services on April 19, 2020. The ambulance benefit is a 
transportation benefit. When there is no transport, neither Medicare nor the Plan pays for the services provided. 
Therefore, we decided that the Plan does not have to pay for ambulance services on April 19, 2020.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ultrasound (76536) provided on November 13, 2019 by 
an out of network (OON) provider. 
 
You asked the Plan to pay for an OON ultrasound. You say that this should be covered. The Plan denied your 
request. The Plan says this service is not covered out of network. 
 
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 services at issue in this appeal. The Plan did not pre-approve the service at issue. 
This service is excluded from the POS benefit. 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 the ultrasound (76536) provided on 
November 13, 2019 by an out of network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the medical services provided on January 15, 2020 by an out 
of network (OON) provider. 
 
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 the services were provided by a non-contracted provider in the plan service area 
were not for an urgent or emergent reason, and were available to be provided in-network and were not 
authorized as required. 
 
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 15, 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 general health panel provided on July 17, 2019. 
 
You asked the Plan to pay for the lab service. The Plan denied your request. The Plan says the service is not 
payable by Medicare. 
 
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 looked at the file and the rules. We find that CPT code 80050 is not covered by any Medicare outpatient 
benefit category. This service is not covered by Medicare. 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 general 
health panel provided on July 17, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for enteral nutrition infusion pump (CPT 
Code B9002) provided on March 13, 2020. 
 
You asked the Plan to waive the coinsurance for the DME. You say that you are appealing your cost-share 
responsibility for the services you received. The Plan denied your request. The Plan says the claim was 
processed accordingly with your 2020 EOC benefits. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance).  
 
Review of the file show that you received an enteral nutrition infusion pump on March 13, 2020. You are asked 
to pay 20% coinsurance for the DME. Your EOC states that enrollees must pay 20% of the cost for DME and 
supplies. 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 enteral nutrition infusion pump (CPT Code 
B9002) provided on March 13, 2020.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the Comprehensive Genomic Profile (CGP) testing provided 
on September 22, 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) testing provided on September 22, 2019.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an ambulance trip provided by a 
participating provider on April 10, 2020. 
 
You asked the Plan to waive the copayment for an ambulance trip. You say that you do not agree with this 
copayment. 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 $225 
copayment for ambulance service/ground.  
 
You have been asked to pay a $225 copayment for an ambulance trip. An ambulance trip falls within the 
ambulance service/ground 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 an 
ambulance trip provided by a participating provider on April 10, 2020.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services provided on December 2, 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 a physician order is not required to be signed, 
however, the physician must clearly document, in the medical record, his or her intent that the test be 
performed. 
 
We looked at the file and Medicare rules. We find that payment for the lab services is not supported in the 
medical record. We find that the issue of intent is not clear. There are no medical records in the case file in 
regards to the physician's intent that the test be performed prior to services taking place. Therefore, we decided 
that the Plan does not have to pay for the laboratory services provided on December 2, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the medical services provided on November 25, 2019 by an 
out of network (OON) provider. 
 
You asked the Plan to pay for the medical services. You say that your physicians depend on the patient's 
facility to get any 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 provider in this case is not a network provider with the Plan. The Plan had network providers available 
who could 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 25, 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) testing provided 
on April 15, 2020. 
 
You asked the Plan to pay for the CGP testing. You say that you would like the Plan to reconsider their denial 
of payment. The Plan denied your request. The Plan says the services are not covered. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
We find that the various denied CPT codes are not supported in the medical record. Specifically, the testing at 
issue in this case should be reported with CPT 81479. Based on this information, we decided that Medicare 
rules for coverage of the CGP testing have not been met. Therefore, we decided that the Plan does not have to 
pay for the Comprehensive Genomic Profile (CGP) testing provided on April 15, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the physician services provided on November 21, 2019 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 November 21, 
2019 by an out of network (OON) provider.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for CPT code G0249 provided on February 28, 2020. 
 
You asked the Plan to pay for CPT code G0249. 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 code G0249 is allowed once every 25 days.  
 
We looked at the file and Medicare rules. The records show that code G0249 was paid by the Plan for date of 
service February 16, 2020. The services in question were provided less than 25 days after the paid services. 
Based on this information, we decided that Medicare rules for coverage of CPT code G0249 have not been met. 
Therefore, we decided that the Plan does not have to pay for CPT code G0249 provided on February 28, 2020.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the Guardant 360 panel provided on April 15, 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 15, 2020.
Appeal type: Hospice
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the subsequent hospital care services provided on December 
10, 2019. 
 
You asked the Plan to pay for the subsequent hospital care services. You say that the enrollee was taken off of 
hospice on December 9, 2019 and put back on hospice on February 27, 2020. 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. Original Medicare is responsible for payment for services until the first day of the month after the 
hospice election has been revoked or terminated. 
 
The enrollee ended Medicare Hospice benefits on December 9, 2019. The services in question were provided 
before the end of that month. Therefore, we decided that the Plan does not have to pay for the subsequent 
hospital care services provided on December 10, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for enteral nutrition infusion pump (CPT 
Code B9002) provided from January 13, 2020 through February 13, 2020. 
 
You asked the Plan to waive the coinsurance for the DME. You say that you are appealing your cost-share 
responsibility for the services you received. The Plan denied your request. The Plan says the claims were 
processed accordingly with your 2020 EOC benefits. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance).  
 
Review of the file show that you received an enteral nutrition infusion pump from January 13, 2020 through 
February 13, 2020. You are asked to pay 20% coinsurance per date of service for the DME. Your EOC states 
that enrollees must pay 20% of the cost for DME and supplies. 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 enteral nutrition infusion pump (CPT Code B9002) provided from January 13, 2020 through February 13, 
2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for CPT code 99153 provided on April 24, 2020. 
 
You asked the Plan to pay for CPT code 99153. 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. 
 
We looked at the file and Medicare rules. In this case, the review shows that the medical records provided 
represent professional charges; however, procedure code 99153 was provided in a facility with a place of 
service code of 21. Procedure code 99153 has a PC/TC Modifier Status of 3, which specifies a Technical 
Component only code. Therefore, we decided that the Plan does not have to pay for CPT code 99153 provided 
on April 24, 2020.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the Guardant 360 panel provided on December 16, 2019. 
 
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 December 16, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the endodontic therapy provided on March 26, 2020. 
 
You asked the Plan to pay for the endodontic therapy. You say that the service for a root canal was an 
emergency, which you believe should be an exception. The Plan denied your request. The Plan says this service 
is not covered. 
 
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. Therefore, we decided that the Plan does not have to pay for the 
endodontic therapy provided on March 26, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for inpatient hospital care provided to the enrollee from January 31, 2020 through February 7, 2020.

You asked the Plan to waive the copayment for inpatient hospital care. You say that this stay was necessary for the potential of the enrollee having COVID-19 and the costs need to be covered under the CARES Act. The Plan denied your request. The Plan says the claim was processed accordingly with the member's 2019 EOC benefits.

The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). 

Review of the file shows that the enrollee was admitted on January 31, 2020 and discharged on February 7, 2020. The enrollee was asked to pay a $375 copayment per day from January 31, 2020 through February 4, 2020, days 1-5 of their inpatient stay. There were no copayment charges from February 5, 2020, day 6 of the enrollee's inpatient hospital care until their day of discharge February 7, 2020. Per the enrollee's contract there is a $250 copayment per day required for days 1-5 for in-network inpatient hospital care. This means that the enrollee has been asked to pay the correct amount based on the contract with the Plan. This cost sharing is a contractual obligation the enrollee agreed to pay upon enrolling in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for inpatient hospital care provided to the enrollee from January 31, 2020 through February 7, 2020.