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

 
We decided that the Plan does not have to pay for a PET Scan (78815) provided on March 6, 2020. 
 
You asked the Plan to pay for the PET Scan. You say that you would like reconsideration based on the records 
submitted. The Plan denied your request. The Plan says this claim was billed with an inappropriate diagnosis 
code. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly.  
 
We find that CPT code 78815-26 PI is not supported in the record. Specifically, Chapter 13 of the Medicare 
Claims Processing Manual includes a list of appropriate diagnosis codes for PET for the initial treatment 
strategy. Diagnosis code C85.90 is not included on the list of appropriate codes. Based on this information, we 
decided that Medicare rules for coverage of the PET Scan have not been met. Therefore, we decided that the 
Plan does not have to pay for a PET Scan (78815) provided on March 6, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for core buildup, including any pins when required (D2950) 
provided on April 30, 2020. 
 
You asked the Plan to pay for the dental services. You say that you are appealing for reconsideration of the 
denied charges. The Plan denied your request. The Plan says the service is not a covered benefit under the plan. 
 
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. Procedure code D2950 is not covered when not performed together 
with a crown. You must pay all fees for non-covered services to the dentist at the time of service. The health 
plan contract says core buildup, including any pins when required (D2950) is covered one (1) procedure per 
tooth every five (5) years and has to be performed together with a crown. Therefore, we decided that the Plan 
does not have to pay for core buildup, including any pins when required (D2950) provided on April 30, 2020.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for non-emergent transportation (T2005 and A0425) provided on 
May 8, 2020. 
 
You asked the Plan to pay for the transportation. You say that you would like reconsideration based on the 
records submitted. The Plan denied your request. The Plan says T codes are not accepted 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 find that CPT code T2005 and A0425 is not supported in the record. Specifically, per the Physician Fee 
Schedule, CPT code T2005 has a status indicator of I. This means that CPT code T2005 is not valid for 
Medicare purposes. Additionally, CPT code A0425 also denied because it was billed in conjunction with code 
T2005. Based on this information, we decided that Medicare rules for coverage of the transportation have not 
been met. Therefore, we decided that the Plan does not have to pay for non-emergent transportation (T2005 and 
A0425) provided on May 8, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the routine podiatry services provided on February 26, 2019 
to July 22, 2019 by an out of network (OON) provider. 
 
You asked the Plan to pay for the podiatry service. You say that the authorization should have been obtained by 
the facility or referring physician. Your doctors see these patients in good faith and should be paid for the 
services provided. The Plan denied your request. The Plan says enrollee's must receive their medical services 
from an in-network provider. Non-emergent services with non-contracted providers require prior-authorization 
prior to services being rendered. 
 
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 routine podiatry services provided on February 
26, 2019 to July 22, 2019 by an out of network (OON) provider.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pay for SNF care provided to the enrollee from February 15, 2020 
through March 1, 2020 and March 6, 2020 through March 15, 2020. 
 
You asked the Plan to pay for SNF care. You say that the stay was medically necessary. The Plan denied your 
request. The Plan says the stay is not medically necessary. 
 
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 pay for SNF care. Our reviewer says that daily 
skilled services are not necessary. Our physician reviewer found there are no identifiable skilled nursing 
service needs. There are no identifiable skilled therapy service needs. The beneficiary does not require skilled 
nursing or therapy services on a daily basis. This beneficiary does not meet severity of illness or intensity of 
service criteria for an inpatient basis in a skilled nursing facility 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 care have not been met. Therefore, we decided that the Plan does not have 
to pay for SNF care provided to the enrollee from February 15, 2020 through March 1, 2020 and March 6, 2020 
through March 15, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the subsequent nursing facility care, per day (99309) 
rendered by the out of network (OON) provider on June 1, 2020. 
 
You asked the Plan to pay for this service. You say that you are requesting a reconsideration of the Plan's 
denial for payment. The Plan denied your request. The Plan says the service was rendered 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 service at issue in this appeal. The Plan did not pre-approve the service at issue. We found 
no exception that would require the Plan to pay for this service. Therefore, we decided that the Plan does not 
have to pay for the subsequent nursing facility care, per day (99309) rendered by the out of network (OON) 
provider on June 1, 2020.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to reimburse you for the home health services provided from February 24, 2020 to February 28, 2020. 
 
You asked the Plan to reimburse you for the home health services. You say that you did not know the provider 
was not certified for Medicare. The Plan denied your request. The Plan says this provider is not certified for 
Medicare. 
 
The Plan must follow Medicare rules. The rules say that no Medicare payment may be made to a beneficiary 
for items or services provided directly by a physician or practitioner who has opted out of the program except 
in cases involving emergencies or urgently needed care. 
 
The services at issue in this appeal were provided in a non-urgent, non-emergent situation by the provider. This 
provider has opted out of the Medicare program. Therefore, we decided that the Plan does not have to 
reimburse you for the home health services provided from February 24, 2020 to February 28, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the outpatient hospital injections provided 
on April 13, 2020 and May 12, 2020. 
 
You asked the Plan to waive the copayment for the outpatient hospital injections. 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 injections in an outpatient hospital setting on the 
dates of service at issue in this appeal. The Plan says the correct copayments have 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 $200 
copayment for Outpatient hospital services.  
 
We looked at the file, the Plan's contract and Medicare rules. The file shows that you received injections in an 
outpatient hospital setting on April 13, 2020 and May 12, 2020. You have been asked to pay a $159.55 
copayment for the outpatient hospital injections, which is less than the contracted $200 copayment amount for 
the April 13, 2020 date of service. You have been asked to pay a $166.40 copayment for the outpatient hospital 
injections, which is less than the contracted $200 copayment amount for the May 12, 2020 date of service. The 
outpatient hospital injections fall within the Outpatient hospital services benefit category. This means that you 
have been asked to pay the correct amounts 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 outpatient hospital injections provided on April 13, 2020 and 
May 12, 2020.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the definitive drug testing panel provided on February 4, 
2020 billed with code G0483. 
 
You asked the Plan to pay for the definitive panel. You say that the records support the billed services. The 
Plan denied your request. The Plan says the lab report does not support code G0483. 
 
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 G0483 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; 22 or 
more drug class(es), including metabolite(s) if performed. 
 
We find that CPT code G0483 is not supported in the medical record. Specifically, review of the lab report 
shows that only 19 drug classes were resulted from this testing. Based on this information, we decided that 
Medicare rules for coverage of the definitive panel have not been met. Therefore, we decided that the Plan does 
not have to pay for the definitive drug testing panel provided on February 4, 2020 billed with code G0483.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the additional intraoral x-ray (D0230), oral hygiene 
instructions (D1330) and unspecified periodontal procedure (D4999) provided on March 12, 2020. 
 
You asked the Plan to pay for the additional intraoral x-ray (D0230), oral hygiene instructions (D1330) and 
unspecified periodontal procedure (D4999). You say that the payment amount to the dentist should be 
reviewed. The Plan denied your request. The Plan says the services are not covered benefits. 
 
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. The Plan has confirmed that the dentist office is not charging you for 
the additional intraoral x-ray and oral hygiene instructions. Therefore, we decided that the Plan does not have 
to pay for the additional intraoral x-ray (D0230), oral hygiene instructions (D1330) and unspecified periodontal 
procedure (D4999) provided on March 12, 2020.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the laboratory services (84439, 84443, 
36415) provided on May 28, 2020. 
 
You asked the Plan to waive the copayment. You say that you are requesting a reconsideration of the Plan's 
denial for payment. The Plan denied your request. The Plan says the copayment has been applied correctly to 
the services provided. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). The enrollee's contract with the Plan clearly says that enrollees 
must pay a $7 copayment for in-network Medicare-covered laboratory services.  
 
The enrollee has been asked to pay a $7 copayment for the in-network Medicare-covered laboratory services 
provided. 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 the laboratory services (84439, 
84443, 36415) provided on May 28, 2020.  
 
Your complaint that the laboratory services should not have been rendered as you did not have prior knowledge 
of the request to have bloodwork drawn is not a valid appeal for medical coverage. This part of your complaint 
is a grievance that must be answered by the Plan. Medicare does not permit us to make a decision about these 
types of complaints.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for provision of test materials and equipment for home INR 
monitoring of patient with either mechanical heart valve(s), chronic atrial fibrillation, or venous 
thromboembolism who meets Medicare coverage criteria; includes: provision of materials for use in the home 
and reporting of test results to physician; testing not occurring more frequently than once a week; testing 
materials, billing units of service include 4 tests (CPT Code G0249) provided on February 18, 2020. 
 
You asked the Plan to pay for the services. You say that the claim should be paid. The Plan denied your 
request. The Plan says the Medicare rules have not been met. 
 
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. Current procedure Code G0249 is 
not supported on appeal as NCD 190.11 Prothrombin Time/International Normalized Ratio (PT/INR) 
Contractors shall delete Current Procedural Terminology (CPT) 93792, 93793 effective January 1, 2018 added 
to NCD in error. Contractors shall be aware of frequency edit change to Multi- Carrie System (MCS) 233A 
effective October 1, 2018 and removal of override. MCS to change frequency in audit 233A from 29 days to 25 
days, remove override, and add G0249 effective October 1, 2018. The Plan shall allow G0249, G0250 no more 
frequently than once every 4 weeks. MCS audit 233A. You can find the guidance in the National Coverage 
Determination (NCD) for Home Prothrombin Time/International Normalized Ratio (PT/INR) Monitoring for 
Anticoagulation Management (190.11). Therefore, we decided that the Plan does not have to pay for provision 
of test materials and equipment for home INR monitoring of patient with either mechanical heart valve(s), 
chronic atrial fibrillation, or venous thromboembolism who meets Medicare coverage criteria; includes: 
provision of materials for use in the home and reporting of test results to physician; testing not occurring more 
frequently than once a week; testing materials, billing units of service include 4 tests (CPT Code G0249) 
provided on February 18, 2020.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pay for skilled nursing facility (SNF) services provided to the 
enrollee from November 15, 2019 to December 8, 2019. 
 
You asked the Plan to pay for SNF services provided to the enrollee. You say that this care should be covered 
for the enrollee. The Plan denied your request. The Plan says the care from November 15, 2019 to December 8, 
2019 was custodial in nature. The Plan covered dates of service December 9, 2019 to December 14, 2019 due 
to the development of shortness of breath. 
 
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. Based on the records provided, the enrollee did not require 
daily skilled nursing or skilled therapy services from November 15, 2019 to December 8, 2019. Therefore, we 
decided that the Plan does not have to pay for skilled nursing facility (SNF) services provided to the enrollee 
from November 15, 2019 to December 8, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for anesthesia for diagnostic or therapeutic nerve blocks and 
injections (when block or injection is performed by a different physician or other qualified health care 
professional); prone position (CPT Code 01992) provided to the enrollee on April 13, 2020 
 
You asked the Plan to pay for the services. You say that the services were medically necessary. The Plan 
denied your request. The Plan says no medical records were provided. 
 
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. Medical records were requested 
twice from this appealing provider, but the records were not received. For this reason, we are upholding the 
original claim denial decision issued because without the medical records requested, a review could not be 
conducted to determine medical necessity. Therefore, we decided that the Plan does not have to pay for 
anesthesia for diagnostic or therapeutic nerve blocks and injections (when block or injection is performed by a 
different physician or other qualified health care professional); prone position (CPT Code 01992) provided to 
the enrollee on April 13, 2020
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for WATS 3D testing provided on July 23, 2019. 
 
You asked the Plan to pay for laboratory testing. You say that you are appealing with records. The Plan denied 
your request. The Plan says the denial of payment for this testing is correct, because the clinical value and 
effectiveness of this testing have not been established in peer-reviewed medical literature. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are 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 pay for laboratory testing. Our reviewer says that the 
requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found while it is speculated that WATS 3D biopsy testing can potentially improve the management 
and improve outcomes of patients with Barrett's esophagus and esophageal dysplasia, there is not high-quality 
evidence in medical literature demonstrating that such testing improves the management and outcomes of such 
patients. Furthermore, the enrollee does not have a diagnosis of Barrett's esophagus. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of laboratory testing have not been met. Therefore, we decided that the Plan does 
not have to pay for WATS 3D testing provided on July 23, 2019.
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: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pre-approve a paravertebral sympathetic injection for the enrollee. 
 
You asked the Plan to pre-approve the injection. You say that this is medically necessary. The Plan denied your 
request. The Plan says that there are no records showing CRPS. 
 
The Plan must follow Medicare rules. Medicare rules say that if there are no specific coverage rules for an item 
or service, then that item or service will be covered when it is medically necessary.  
 
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 the injection. Our reviewer says that the 
requested injection is considered medically reasonable and necessary in this case. Our physician reviewer 
found the enrollee has metastatic prostate and rectal cancer. A ganglion impar block for rectal and prostate 
cancer pain relief is standard of care.  The requested procedure is medically reasonable and necessary. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the injection have been met. Therefore, we decided that the Plan has to pre-
approve a paravertebral sympathetic injection for the enrollee.  
 
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.