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

 
We decided that the Plan does not have to waive the deductible for initial observation care (99219) on January 
22 to January 23, 2019. 
 
You asked the Plan to waive the deductible for initial observation care. You say that a representative of the 
Plan told you that the provider had made an error in billing. 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. Your 
contract with the Plan says that there is an $800 deductible that applies to outpatient care.  
 
The item or service you asked the Plan to waive the deductible for falls within the benefit category Outpatient 
hospital services." In this case, the record shows that initial observation care was provided in an outpatient 
hospital and not in the emergency room. The Plan has followed Medicare rules by clearly disclosing in the 
contract that there is an $800 deductible that applies to outpatient care. This cost sharing is a contractual 
obligation that had not been met at the time initial observation care was received on January 22, 2019 to 
January 23, 2019. Therefore, we decided that the Plan does not have to waive the deductible for initial 
observation care (99219) on January 22 to January 23, 2019.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ambulance services provided by you. 
 
You asked the Plan to pay for the ambulance services. You say that you were following the COVID executive 
order for treatment in place. 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 14, 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 the ambulance services provided by you.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an emergency room visit (99283).
 
You asked the Plan to waive the copayment for an emergency room visit. You say that you were unable to 
obtain a lower level of care due to closures related to the COVID-19 pandemic. 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 $100 
copayment for each Medicare-covered emergency room visit.  
 
You have been asked to pay a $100 copayment for an emergency room visit. An emergency room visit falls 
within the "Emergency 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 an 
emergency room visit (99283).
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ambulance services provided by you. 
 
You asked the Plan to pay for the ambulance services. You say that you were following the COVID executive 
order for treatment in place. 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. 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 the ambulance services provided by you.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pay for medical nutrition therapy. 
 
You asked the Plan to pay for medical nutrition therapy. You say that this was medically necessary. The Plan 
denied your request. The Plan says this is not covered for the enrollee's condition. 
 
The Plan must follow Medicare rules. Medicare rules say that medical nutrition therapy services (MNT) is 
covered for certain beneficiaries who have diabetes or a renal disease. 
 
We looked at the file and Medicare rules. The record does not show that the enrollee has diabetes or renal 
disease. Based on this information, we decided that Medicare rules for coverage of medical nutrition therapy 
have not been met. Therefore, we decided that the Plan does not have to pay for medical nutrition therapy.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for ambulance transportation provided on December 1, 2019. 
 
You asked the Plan to pay for ambulance transport. You say that you are appealing. The Plan denied your 
request. The Plan says the denial of payment for this service is correct, because the enrollee was enrolled in a 
hospice program on this date of service and therefore the Plan is not responsible for payment. 
 
Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice 
services. Medicare hospice pays for claims related to the terminal illness. The rules say that the Plan may direct 
the provider to bill Medicare directly for these services.  
 
The enrollee was under the Medicare hospice benefit for the dates of service at issue in this appeal. Therefore, 
we decided that the Plan does not have to pay for ambulance transportation provided on December 1, 2019.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the Guardant360 testing provided on May 13, 2020. 
 
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 
billed with code 81479. In addition, the appropriate DEX Z code identifier should be entered adjacent 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 May 13, 2020.
Appeal type: Inpatient Hospital
Decision: Favorable

 
We decided that the Plan has to pay for the acute inpatient hospital care provided. 
 
You asked the Plan to pay for acute inpatient hospital care. You say that you would like the plan to reconsider 
their denial. The Plan denied your request. The Plan says that the services rendered were 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 supports that the criteria for inpatient payment are met in this case. Our physician 
reviewer found the enrollee has a recent surgery and presented with leukocytosis and wound dehisnce in need 
of surgical repair. The documentation supports that it was reasonable to expect two or more midnights with 
acute and chronic conditions. Therefore, the enrollee met criteria for the inpatient services provided. 
 
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 been met. Therefore, we decided that the Plan 
has to pay for the acute inpatient hospital care provided.  
 
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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the emergency department visit. 
 
You asked the Plan to pay for the emergency department visit. You say that the claim denied as patient is 
enrolled in a Hospice. Resubmitting the claim as pay to address is correct. Not a credentialing issue. Please 
review for payment. The Plan denied your request. The Plan says the enrollee was enrolled in a federal hospice 
program during the time services were rendered. Original Medicare would be responsible for payment of all 
Medicare covered services related or unrelated to the member?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 February 1, 2020. 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 emergency 
department visit.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the medical services by an out 
of network (OON) provider. 
 
You asked the Plan to pay for nursing facility care (99308). You say that you would like reconsideration 
because it is the responsibility of the facility to obtain authorization. The Plan denied your request. The Plan 
says utilization of network providers is required when possible and available. 
 
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 by an out of network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for assembly and operation of pump with oxygenator or heat 
exchanger provided on April 20, 2020. 
 
You asked the Plan to pay for the special pump services (99190). You say that this equipment was provided to 
the enrollee during an inpatient stay and should be covered. The Plan denied your request. The Plan says this 
claim cannot be paid separately based on Medicare guidelines for inpatient services. 
 
The Plan must follow Medicare rules. Medicare rules say that CMS does not pay any provider or supplier other 
than the facility or hospital for services furnished to a beneficiary. The facility or hospital must furnish all 
necessary covered services to the beneficiary either directly or under arrangements made with outside 
providers.  
 
This equipment was used during and after a surgical procedure by 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 
or hospital. Therefore, we decided that the Plan does not have to pay for assembly and operation of pump with 
oxygenator or heat exchanger provided on April 20, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for discharge day management (99239) provided on October 15, 
2019. 
 
You asked the Plan to pay for discharge day management. You say that this was medically necessary. The Plan 
denied your request. The Plan says this code 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 99239 is hospital discharge day management; more than 
30 minutes. 
 
We find that CPT code 99239 is not supported in the medical record. Specifically, this code is for 31 minutes 
or more and the time spent on this service is not documented in the record. Based on this information, we 
decided that Medicare rules for coverage of discharge day management have not been met. Therefore, we 
decided that the Plan does not have to pay for discharge day management (99239) provided on October 15, 
2019.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for arthrodesis, combined posterior or posterolateral fusion 
performed at the same interspace and segment(22633) laminotomy (hemilaminectomy), with decompression of 
nerve roots(63030) provided July 5, 2019. 
 
You asked the Plan to pay for the orthopaedic services. You say that there is no other claim for this date of 
service with the same services or provider specialty under the enrollee's account. Please review and reprocess 
as a new claim. The Plan denied your request. The Plan says the records do not support the services being 
performed by the rendering provider more than once for this date of service. This service exceeds the 
maximum number allowed per day. 
 
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 records show that this service was already processed and paid a total of $3,846.62 on check 
dated July 15, 2019. Based on this information, we decided that Medicare rules for coverage of the orthopaedic 
services have not been met. Therefore, we decided that the Plan does not have to pay for arthrodesis, combined 
posterior or posterolateral fusion performed at the same interspace and segment(22633) laminotomy 
(hemilaminectomy), with decompression of nerve roots(63030) provided July 5, 2019.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for comprehensive genomic profile (CGP) testing provided on 
June 28, 2019. 
 
You asked the Plan to pay for genetic testing. You say that the enrollee's treating physician ordered this testing 
to determine if there was a more effective therapy to treat the enrollee's condition. The Plan denied your 
request. The Plan says the denial of payment for this testing is correct, because this testing was not billed with 
the appropriate coding. 
 
The Plan must follow Medicare rules. Medicare rules say that CGP testing must be billed with CPT code 81479 
for date of service June 28, 2019.  
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of genetic testing have not been met. Therefore, we decided that the Plan does not have to pay for 
comprehensive genomic profile (CGP) testing provided on June 28, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for assembly and operation of pump with oxygenator or heat 
exchanger (with or without ECG and/or pressure monitoring); each hour (CPT Code 99190) provided on April 
28, 2020. 
 
You asked the Plan to pay for the services. You say that it takes a half hour to an hour to setup the machine. 
You state the perfusionist is required to be in the operating room during the length of the procedure. You state 
per hospital protocol it is mandatory that the surgeon. You state the anesthesiologist and perfusionist transport 
the patient to the unit and be there until the patient is in stable condition. The Plan denied your request. The 
Plan says the Medicare rules have not been met. The Plan states that if the provider determines that a billing 
error occurred during the initial submission of the denied claim, the plan would accept a submission of a 
corrected claim to consider services for payment. 
 
The Plan must follow Medicare rules. We looked at the file and Medicare rules. Based on this information, we 
decided that Medicare rules for coverage of the services have not been met. The rules say that all items and 
non-physician services furnished to inpatients must be furnished directly by the hospital or billed through the 
hospital under arrangements. This provision applies to all hospitals regardless of whether they are subject to 
PPS. Therefore, we decided that the Plan does not have to pay for assembly and operation of pump with 
oxygenator or heat exchanger (with or without ECG and/or pressure monitoring); each hour (CPT Code 99190) 
provided on April 28, 2020.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a mammogram (77061) performed April 29, 2019. 
 
You asked the Plan to pay for the mammogram. You say that the service was medically necessary. The Plan 
denied your request. The Plan says the code billed is not a valid code. 
 
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 CPT code 77061 is not supported in the medical record. Specifically, per the 2019 National 
Physician Fee Schedule Relative Value File April Release, procedure code 77061 has status code of ?I? which 
is not valid for Medicare purposes. Based on this information, we decided that Medicare rules for coverage of 
the mammogram have not been met. Therefore, we decided that the Plan does not have to pay for a 
mammogram (77061) performed April 29, 2019.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for hereditary cancer screening panel provided on January 16, 
2020. 
 
You asked the Plan to pay for genetic testing. You say that the enrollee has no choice in which lab did this 
testing. The Plan denied your request. The Plan says the denial of payment for these services is correct, because 
this claim was not billed with appropriate coding. 
 
The Plan must follow Medicare rules. Medicare rules say that if an independent lab bills for services, the place 
where the sample was taken is reported as the Place of Service (POS) code.  
 
We looked at the file and Medicare rules. This testing was billed with Place of Service (POS) code 81 ? 
indicating an independent laboratory setting ? however the documentation submitted does not support that the 
sample for this testing was taken in an independent laboratory setting. Therefore, POS code 81 is not 
appropriate for this claim. Based on this information, we decided that Medicare rules for coverage of genetic 
testing have not been met. Therefore, we decided that the Plan does not have to pay for hereditary cancer 
screening panel provided on January 16, 2020.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to waive the deductible for the impacted cerumen procedure provided 
on June 26, 2020. 
 
You asked the Plan to waive the deductible for the impacted cerumen procedure. You say that you never had to 
pay for this service before. The Plan denied your request. The Plan says you were charged this deductible 
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 there is a $750 deductible for covered medical services.  
 
The item or service you asked the Plan to pay for falls within the benefit category covered medical services. 
The Plan has followed Medicare rules by clearly disclosing in the contract that there is a $750 deductible for 
covered medical services. This cost sharing is a contractual obligation that had not been met at the time the 
impacted cerumen procedure was received on June 26, 2020. Therefore, we decided that the Plan does not have 
to waive the deductible for the impacted cerumen procedure provided on June 26, 2020.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the assembly and operation of a pump with an oxygenator or 
heat exchanger (99190) provided on April 27, 2020. 
 
You asked the Plan to pay for the assembly and operation of a pump with an oxygenator or heat exchanger. 
You say that this was a mandatory service. The Plan denied your request. The Plan says payment for this 
service is included in the DRG. 
 
The Plan must follow Medicare rules. The rules say that there is no payment under the OPPS for services that 
CMS designates to be ?inpatient-only? services. These services have an OPPS status indicator of ?C? in the 
OPPS Addendum B and are listed together in Addendum E of each year?s OPPS/ASC final rule.  
 
The service at issue in this appeal was billed with CPT code 99190. This code is listed with a status indicator of 
?C? on Addendum B of the 2020 OPPS/ASC final rule. This means the service has been designated as 
?inpatient only?, and therefore must be billed as part of an inpatient admission. Therefore, we decided that the 
Plan does not have to pay for the assembly and operation of a pump with an oxygenator or heat exchanger 
(99190) provided on April 27, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit. 
 
You asked the Plan to pay for an office visit. You say that the original claim was filed timely. The Plan denied 
your request. The Plan says corrected claims are held to the same timeliness standards as original claims. 
 
The Plan follows Medicare rules. The rules say that claims for services furnished on or after January 1, 2010 
must be filed no later than one calendar year after the date of service. 
 
The record shows that this claim for an office visit. This means that more than 
one calendar year from the date of service had passed before a claim was filed. Therefore, we decided that the 
Plan does not have to pay for an office visit.