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

 We decided that the Plan does not have to pay for the medical services provided on March 26, 2020 by an out 
of network (OON) provider. 
 
You asked the Plan to pay for the medical services. You say that these services were provided without 
obtaining authorization in order to avoid delay in care which could result in complications. The Plan denied 
your request. The Plan says the services provided were not authorized and are not considered emergent. 
Authorization to provided OON care could have been requested. 
 
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 March 26, 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 drug testing coded G0482 provided on November 25,
2019.
You asked the Plan to pay for the drug testing. You say that you would like the plan to reconsider their denial.
The Plan denied your request. The Plan says the services billed are not supported by the documentation.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly.
Providers must report services with the appropriate CPT code.
We find that CPT code G0482 is not supported in the medical record. Specifically, the documentation
submitted did not include a valid physician order/lab requisition form or medical records signed by the ordering
physician for the billed test. Based on this information, we decided that Medicare rules for coverage of the drug
testing have not been met. Therefore, we decided that the Plan does not have to pay for the drug testing coded
G0482 provided on November 25, 2019.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the blood smear services coded 85060 provided on 
December 26, 2019. 
 
You asked the Plan to pay for the blood smear services. You say that you would like the plan to reconsider 
their denial. The Plan denied your request. The Plan says the services billed are not payable. 
 
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 85060 is blood smear, peripheral, interpretation by 
physician with written report. 
 
We find that CPT code 85060 is not supported in the medical record. Specifically, this code has a professional 
component/technical component of 8. This code is not payable if furnished to hospital outpatients or non-
hospital patients. This service was billed with place of service 22, outpatient hospital. Based on this 
information, we decided that Medicare rules for coverage of the blood smear services have not been met. 
Therefore, we decided that the Plan does not have to pay for the blood smear services coded 85060 provided on 
December 26, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided on April 6, 2020 by an out of network (OON) provider.
You asked the Plan to pay for the chiropractic services. You say that you would like reconsideration based on the records submitted. The Plan denied your request. The Plan says you must get your care from network providers.
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 April 6, 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 Guardant360 panel rendered on February 24, 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 24, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the ECG, with at least 12 leads; with 
interpretation and report (CPT Code 93000) on May 26, 2020. 
 
You asked the Plan to waive the copayment for the ECG. You say that you should not be billed the copayment 
for this service because you have never paid it in the past. 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 ECG performed on May 26, 2020. You are asked to pay a $10 
copayment for the ECG. Your EOC states, "enrollees must pay a $10 copayment for diagnostic lab services and 
diagnostic procedures and tests (per day, per facility). This excludes basic and advanced diagnostic imaging 
services." 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 ECG, with at least 12 leads; with 
interpretation and report (CPT Code 93000) on May 26, 2020.
Appeal type: Lab
Decision: Unfavorable

 We decided that the Plan does not have to pay for the Guardant360 panel rendered on March 9, 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 March 9, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the assistant surgeon services provided on January 6, 2020.
You asked the Plan to pay for the services. The Plan denied your request. The Plan says this provider is not eligible for payment.
The Plan follows Medicare rules. The rules say that Medicare only pays for assistant surgery services when the procedure is covered for an assistant and the person who assists the surgery bears the designation of a physician, PA, NP, or CNS. In this case, the record does not show that the provider of the surgical assistant service is a physician, PA, NP, or CNS. Medicare only makes payment for surgical assistant services when provided by one of these types of practitioners. Therefore, we decided that the Plan does not have to pay for the assistant surgeon services provided on January 6, 2020.
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 February 3, 2020 billed with multiple line items of different CPT codes.
You asked the Plan to pay for the Guardant360 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 February 3, 2020 billed with multiple line items of different CPT codes.
Appeal type: Inpatient Hospital
Decision: Favorable

 
We decided that the Plan has to pay for inpatient hospital care provided to the enrollee from September 2, 2019 
and September 4, 2019 
 
You asked the Plan to pay for inpatient hospital care. You say that the stay was medically necessary. The Plan 
denied your request. The Plan says that the stay is not medically necessary. 
 
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 pay for inpatient hospital care. Our reviewer says 
that the requested items/services are considered medically reasonable and necessary in this case. Our physician 
reviewer found even without the comorbid conditions, the profound hyponatremia clearly meets admission 
criteria by any standard. The admission was reasonable and indicated. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of inpatient hospital care have been met. Therefore, we decided that the Plan has to 
pay for inpatient hospital care provided to the enrollee from September 2, 2019 and September 4, 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: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an outpatient surgery provided a 
participating provider on January 28, 2020. 
 
You asked the Plan to waive the copayment for an outpatient surgery. You say that you are on a limited 
budget and you do not agree with these charges. 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 $425 copayment for hospital outpatient facilities and ambulatory surgical centers.  
 
You have been asked to pay a $425 copayment for an outpatient surgery. The correct copayment has 
been applied to the outpatient surgery that was provided. An outpatient surgery falls within the hospital 
outpatient facilities and ambulatory surgical centers 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 outpatient surgery provided a participating provider on January 
28, 2020.
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 March 18, 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 March 18, 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 comprehensive genomic profile (CGP) testing provided on 
March 23, 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 for 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 correct coding. 
 
The Plan must follow Medicare rules. Medicare rules say that CGP testing should be billed with CPT code 
81479 for date of service March 23, 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 March 23, 2020.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for x-ray services provided on December 16, 2019. 
 
You asked the Plan to pay for the x-ray services. You say that the Plan's denial was not appropriate. The Plan 
denied your request. The Plan says UMR was the primary insurance on the date of service in dispute and the 
provider has to submit a claim to them. The Plan says that, once they receive the EOB from UMR, they will 
process the claim as a secondary payer. 
 
The Plan must follow Medicare rules. The rules state that Medicare plans are considered secondary insurers 
when an enrollee has another type of insurance. This means that the Plan is not responsible for paying for 
services until the claim for those services has gone to the primary insurer. However, plans are still required to 
coordinate their benefits with the primary insurers. Plans can coordinate their benefits with the primary insurers 
in three ways. First, the Plan can send the bill directly to the primary insurer for payment. Second, the Plan can 
direct the provider to send the bill to the primary insurer. Third, the Plan can pay for the services and submit a 
bill for reimbursement to the primary insurer. 
 
The Plan has met its obligation with regards to coordination of benefits. Specifically, the Plan has directed the 
provider to send the bill to the primary insurer. As the secondary insurer, the Plan cannot be held responsible 
for the x-ray services until the primary insurer has denied the claim for these services. Therefore, we decided 
that the Plan does not have to pay for x-ray services provided on December 16, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for anesthesia services (01480) provided on January 17, 2019.
You asked the Plan to pay for anesthesia services. You say that you did not receive information needed to be timely. The Plan denied your request. The Plan says claims must be filed within one year from the date of service.
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 a claim for anesthesia services was not filed until March 10, 2020. 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 anesthesia services (01480) provided on January 17, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the Guardant360 testing provided on March 24, 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 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 March 24, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for a chiropractic office visit (9202) provided on March 4, 2020.
You asked the Plan to pay for a chiropractic office visit. You say that this should be covered because it was you first visit for evaluation. The Plan denied your request. The Plan says chiropractic office visits are not covered by Medicare or the Plan.
The Plan must follow Medicare rules. The rules say that the only chiropractic service Medicare covers is manual manipulation of the spine to correct a subluxation. The records show that the service at issue is not manual manipulation of the spine. Therefore, we decided that the Plan does not have to pay for a chiropractic office visit (9202) provided on March 4, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for wound care provided by a participating provider on March 26, 2020 to April 16, 2020.
You asked the Plan to waive the copayment for an outpatient surgery. You say that you do not agree with these copayments. 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 outpatient surgery. You have been asked to pay a $225 copayment for an outpatient surgery. The total amount you are being asked to pay is $450 ($225 x 2 visits = $450). Wound care is considered an outpatient surgery; therefore, the correct copayment has been applied. An outpatient surgery falls within the outpatient surgery 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 wound care provided by a participating provider on March 26, 2020 to April 16, 2020.
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 March 2, 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 March 2, 2020 billed with multiple line items of 
different CPT codes.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for x-ray services provided on February 17, 2020 by an out of network (OON) provider.
You asked the Plan to pay for the out of network x-ray services. You say that the services in dispute do not require authorization. The Plan denied your request. The Plan says an approved authorization would have been needed before the services in dispute could be 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 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 services 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 x-ray services provided on February 17, 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 subsequent hospital care (99233) provided on January 13, 2020.
You asked the Plan to pay for the subsequent hospital care. You say that you would like reconsideration because these services were medically necessary and rendered in good faith. The Plan denied your request. The Plan says the member was in Hospice on the billed date of service so the claim needs to be submitted to Original Medicare.
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 subsequent hospital care (99233) provided on January 13, 2020.