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

 
We decided that the Plan does not have to pay for long term acute care hospital (LTACH) services provided to 
the enrollee from November 29, 2019 through December 6, 2019. 
 
You asked the Plan to pay for the LTACH services. You say that these services were medically necessary. The 
Plan denied your request. The Plan says that there is no evidence of any unstable medical conditions requiring 
daily physician oversight. 
 
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically 
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 
 
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 the LTACH services. Our reviewer says that 
the requested LTACH care is not considered medically reasonable and necessary in this case. The enrollee did 
not require services at the LTACH that are not available at a less intense level of care such as a skilled nursing 
facility. There were no services available at the LTACH that the enrollee required that were not available at the 
health care setting being offered by the health plan. Our physician reviewer found that the enrollee's condition 
does not meet Medicare criteria for LTACH services. 
 
 
 
 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pay for long term acute care hospital (LTACH) services provided to the enrollee from 
November 29, 2019 through December 6, 2019.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pay for outpatient services provided on March 5, 2020 to March 31, 
2020 by an out of network (OON) provider. 
 
You asked the Plan to pay for outpatient services. You say that you would like this claim reprocessed and 
approved for payment. The Plan denied your request. The Plan says prior authorization was not obtained for 
these services. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The requested provider in this case is not a network provider with the Plan. The Plan has network providers 
available who can provide the items/services at issue in this appeal. The Plan did not pre-approve the 
item/service at issue. We found no exception that would require the Plan to pay for these items/services. 
Therefore, we decided that the Plan does not have to pay for outpatient services provided on March 5, 2020 to 
March 31, 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 surgical services provided on October 25, 2019 billed 
with CPT code 15004. 
 
You asked the Plan to pay for the billed surgical services. You say that this was billed correctly and should be 
paid. The Plan denied your request. The Plan says code 15004 is not supported in the record. 
 
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 15004 is Surgical preparation or creation of recipient site 
by excision of open wounds, burn eschar, or scar (including subcutaneous tissues), or incisional release of scar 
contracture, face, scalp, eyelids, mouth, neck, ears, orbits, genitalia, hands, feet and/or multiple digits; first 100 
sq cm or 1% of body area of infants and children.  
 
We asked our coding 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 the billed surgical services. Our reviewer 
says that the records do not support the use of this code. Our coding reviewer found the procedure report 
documents a 1cm margin being used to remove the extra tissue around the previous excision site that was 
positive in the previous pathology report. This does not meet the definition of code 15004. 
 
We looked at this coders review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the billed surgical services have not been met. Therefore, we decided that the 
Plan does not have to pay for the surgical services provided on October 25, 2019 billed with CPT code 15004.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the acute inpatient hospital care provided on October 1, 
2019. 
 
You asked the Plan to pay for acute inpatient hospital care. You say that these services were medically 
necessary. The Plan denied your request. The Plan says that the care could have been provided without an 
inpatient stay. 
 
The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor 
expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases, 
consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or 
more.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pay for acute inpatient hospital care. Our reviewer 
says that the documentation does not support that the criteria for inpatient payment are met in this case. The 
record did not show that at the time of inpatient admission the admitting physician reasonably expected that  the 
patient's necessary hospital care (including earlier emergency department and/or observation care) would span 
two midnights. Our physician reviewer found that the enrollee's condition does not meet Medicare criteria for 
acute inpatient hospital 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 acute inpatient hospital care have not been met. Therefore, we decided that the 
Plan does not have to pay for the acute inpatient hospital care provided on October 1, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for seat lift mechanism (E0627) and the sales tax (S9999) 
purchased on February 15, 2020 from a non-Medicare provider. 
 
You asked the Plan to pay for the DME. You say that you called the Plan to see what coverage you had for this 
and you were told up to $500. The Plan denied your request. The Plan says you received DME from a provider 
who is not under contract with the health plan and is not certified for Medicare. 
 
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. 
 
Review of the file show that you purchased a seat lift mechanism (E0627) and the sales tax (S9999) on 
February 15, 2020 from a non-Medicare provider. The rules say that to receive payment for covered Medicare 
items or services from either Medicare (in the case of an assigned claim) or a Medicare beneficiary (in the case 
of an unassigned claim), a provider or supplier must be enrolled in the Medicare program. 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. Furthermore, Medicare does not 
reimburse separately for sales tax. Therefore, we decided that the Plan does not have to pay for seat lift 
mechanism (E0627) and the sales tax (S9999) purchased on February 15, 2020 from a non-Medicare provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the inpatient hospital stay provided from 
March 2, 2020 to March 6, 2020. 
 
You asked the Plan to waive the copayment for the inpatient hospital stay. You say that this copayment is too 
high and that you stayed at the hospital longer due to COVID-19. The Plan denied your request. The Plan says 
you have been charged the correct cost sharing amount. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $275 
copayment per day for days 1-5 each time you are admitted to an acute care hospital.  
 
You have been asked to pay a $275 copayment for each day, days 1 to 4 of the inpatient hospital stay. ($275 x 
4 = $1,100). The inpatient hospital stay falls within the ?Inpatient hospital care benefit category. The medical 
record shows that you were not considered a person under investigation/suspected case for COVID-19. You 
were found to have human metapneumovirus. 
 
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 inpatient hospital stay provided from March 2, 2020 to 
March 6, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for dehumidifier (99199) purchased February 7, 2020 from a 
non-Medicare certified provider to be covered under the Wallet benefit. 
 
You asked the Plan to pay for the dehumidifier. You say that you really needed the dehumidifier because you 
were sick. The Plan denied your request. The Plan says this item is not covered and the provider is not eligible 
to participate in Medicare. 
 
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a 
medical purpose.  The rules also say that no provider or supplier shall receive payment for services furnished to 
a Medicare beneficiary unless the provider and supplier enroll in the Medicare program.  
 
The item at issue in this appeal does not serve a purpose that is primarily medical in nature. This item is 
available to the general public and would be helpful even to those who are not sick or injured. Therefore, we 
decided that the Plan does not have to pay for dehumidifier (99199) purchased February 7, 2020 from a non-
Medicare certified provider to be covered under the Wallet benefit.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for train-of-four testing (95999) provided December 16, 2019.

You asked the Plan to pay for train-of-four testing. You say that the services were medically necessary. The Plan denied your request. The Plan says payment for these services were included in payment for another service.

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 95999 has a bundled relationship with code G0453 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 train-of-four testing (95999) provided December 16, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for comprehensive genomic profile (CGP) testing provided on January 29, 2020.

You asked the Plan to pay for genetic testing. You say that the treating physician ordered this testing to determine if there was a more effective therapy to treat the enrollee. 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 January 29, 2020. 

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 January 29, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the drug testing rendered on October 8, 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 there is no valid physician order. 
 
The Plan must follow Medicare rules. Medicare rules say that laboratory services must be ordered by a 
physician. 
 
We looked at the file and Medicare rules. There is no valid physician order in the submitted documentation. 
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 drug testing rendered on October 8, 2019.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the drug testing rendered on September 16, 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 there is no valid physician order. 
 
The Plan must follow Medicare rules. Medicare rules say that laboratory services must be ordered by a 
physician. 
 
We looked at the file and Medicare rules. There is no valid physician order in the submitted documentation. 
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 drug testing rendered on September 16, 2019.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services (88311, 88305, 88312) rendered by 
the out of network (OON) provider on November 29, 2019. 
 
You asked the Plan to pay for these services. You say that you are requesting a reconsideration of the Plan's 
denial for payment. The Plan denied your request. The Plan says the services were provided by an out of 
network provider, without 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 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 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 the laboratory services (88311, 88305, 88312) rendered by the out of network (OON) 
provider on November 29, 2019.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pay for radiation therapy provided on March 4, 2020. 
 
You asked the Plan to pay for radiation therapy. 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 radiation therapy provided on March 4, 2020.
Appeal type: Lab
Decision: Favorable

 
We decided that the Plan has to pay for drug testing services (HCPCS G0482) provided to the enrollee on July 
23, 2019. 
 
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 that the denied code remains 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 HCPCS code G0482 is ?Drug test(s), definitive, utilizing (1) 
drug identification methods able to identify individual drugs and distinguish between structural isomers (but 
not necessarily stereoisomers), including, but not limited to gc/ms (any type, single or tandem) and lc/ms (any 
type, single or tandem and excluding immunoassays (e.g., ia, eia, elisa, emit, fpia) and enzymatic methods 
(e.g., alcohol dehydrogenase)), (2) stable isotope or other universally recognized internal standards in all 
samples (e.g., to control for matrix effects, interferences and variations in signal strength), and (3) method or 
drug-specific calibration and matrix-matched quality control material (e.g., to control for instrument variations 
and mass spectral drift); qualitative or quantitative, all sources, includes specimen validity testing, per day; 15-
21 drug class(es), including metabolite(s) if performed.? 
 
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 the services. Our reviewer says that the 
services at issue in this case were supported by the medical records. Our physician reviewer found the records 
support the code. The laboratory submitted a valid/signed physician laboratory requisition form and lab results. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the services have been met. Therefore, we decided that the Plan has to pay for 
drug testing services (HCPCS G0482) provided to the enrollee on July 23, 2019.  
 
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again 
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake 
and/or send us the new information. This does not happen often. If we decide to open the case again, we will 
send you a letter.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the testing services rendered on March 26, 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 codes 95813, 95861, and 95937 are 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 95813 is electroencephalogram (EEG) extended 
monitoring; greater than 1 hour. The definition of codes 95861 is needle electromyography; 2 extremities with 
or without related paraspinal areas. The definition of code 95937 is neuromuscular junction testing (repetitive 
stimulation, paired stimuli), each nerve, any 1 method. 
 
We find that CPT codes 95813, 95861, and 95937 are not supported in the medical record. Specifically, there is 
no documentation of an EEG extended monitoring for 61-119 minutes to support code 95813. There is no 
documentation of needle electromyography for two extremities to support code 95861. There is no 
documentation of neuromuscular junction testing to support code 95937. 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 testing services rendered on March 26, 2019.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the drug testing rendered on October 10, 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 there is no valid physician order. 
 
The Plan must follow Medicare rules. Medicare rules say that laboratory services must be ordered by a 
physician. 
 
We looked at the file and Medicare rules. There is no valid physician order in the submitted documentation. 
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 drug testing rendered on October 10, 2019.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the Guardant360 panel rendered on February 2, 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 February 2, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for health club membership for the 2019 Health and wellness benefit.
You asked the Plan to pay for health club membership. You say that at the time you were only requesting for benefit year 2018 not 2019. You did not want to be reimbursed for 2019 until you submitted that claim on 03/18/2020. The Plan denied your request. The Plan says the benefit maximum for the Wellness Allowance for 2019 has been paid.
The rules say that Medicare does not cover gym benefits. However, the Plan offers a benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan will reimburse up to $150 each calendar year towards your cost for membership in a qualified health club or fitness facility. The Plan's rules for coverage of gym benefits have not been met because the 2019 Wellness benefit has been paid in full in checks issued 03/19/19 for $19.95 and 05/09/2020 for $160.05. Therefore, we decided that the Plan does not have to pay for health club membership for the 2019 Health and wellness benefit.