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

 
We decided that the Plan does not have to pay for fluoroscopic guidance for a vein device (77001) provided on 
March 11, 2020. 
 
You asked the Plan to pay for the fluoroscopic guidance. You say that you would like reconsideration because 
CPT code 77001 is the add on code to the primary code. The Plan denied your request. The Plan says CPT code 
77001 is the column II procedure to the more comprehensive column I procedure 36584. 
 
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 the 
fluoroscopic guidance has a bundled relationship with code 36584 and cannot be paid as billed. The claim has 
not been submitted with an appropriate modifier to indicate that CPT code 77001 is a distinct service from the 
primary. 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 fluoroscopic guidance 
for a vein device (77001) provided on March 11, 2020.
Appeal type: Lab
Decision: Favorable

 
We decided that the Plan has to pay for testing provided on January 28, 2020. 
 
You asked the Plan to pay for genetic testing. You say that this testing is covered by Medicare. The Plan denied 
your request. The Plan says that the denial of payment for this testing is correct, because this provider is out-of-
network with the Plan and is not certified with Medicare. 
 
Medicare rules say that a contract provider is an agent of the plan. Services and referrals given by a contract 
provider are considered approved by the plan unless notice is provided that the services will not be covered. 
The plan follows these rules. 

This testing was ordered by the enrollee's in-network treating physician. The file does not show that the plan 
provided notice that genetic testing would not be covered. Under Medicare rules, this means genetic testing is 
considered approved by the plan. Therefore, we decided that the Plan has to pay for testing 
provided on January 28, 2020.  
 
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: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for computed tomography, head or brain; without contrast 
material (CPT Code 70450) provided on April 23, 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 CPT code 70450 is a column II procedure to the column I procedure, 70496. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
Based on this information, we decided that Medicare rules for coverage of the services have not been met.  
CPT code 70450-26 billed by the provider, denied as inclusive to CPT code 70496 (Computed tomographic 
angiography, head, with contrast material(s), including noncontrast images, if performed, and image 
postprocessing) which was billed for the same date of service by same provider.   
 
 
 
 
Per CMS CCI procedure to procedure edits, CPT code 70450 is a column II procedure to the column I 
procedure, 70496. However, a modifier is allowed to indicate that these services are distinct.  Per the review of 
the submitted documentation, CPT code 70450 is supported as being performed, but it is not supported as being 
distinct from CPT code 70496. Therefore, the recommendation for CPT code 70450-26 to uphold the original 
denial. Therefore, we decided that the Plan does not have to pay for computed tomography, head or brain; 
without contrast material (CPT Code 70450) provided on April 23, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to reimburse for the services provided on January 1, 2019. 
 
You asked the Plan to reimburse for the services. You say that you do cardiac rehabilitation and it is a program 
designed to help you maintain good health and that this is a covered benefit. The Plan denied your request. The 
Plan says they did not receive proof of payment. 
 
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 covers gym benefits 
only. 
 
The Plan's rules for coverage of gym benefits have not been met. Therefore, we decided that the Plan does not have to reimburse for the services provided on 
January 1, 2019.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for home infusion therapy (S9328) provided on August 8, 2018 
through November 14, 2018. 
 
You asked the Plan to pay for the home infusion therapy. You say that you would like reconsideration because 
this is not a durable medical equipment code and it was not delivered to the member's home. The Plan denied 
your request. The Plan says S codes are not payable by Medicare. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
We find that CPT code S9328 is not supported in the record. Specifically, per the Physician Fee Schedule, CPT 
code S9328 has a status indicator of I. This means that CPT code S9328 is not valid for Medicare purposes. 
Based on this information, we decided that Medicare rules for coverage of the home infusion therapy have not 
been met. Therefore, we decided that the Plan does not have to pay for home infusion therapy (S9328) 
provided on August 8, 2018 through November 14, 2018.
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 20, 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 20, 2020.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the CYP panel provided on April 29, 2019. 
 
You asked the Plan to pay for the CYP panel. The Plan denied your request. The Plan says the services were 
billed incorrectly. 
 
The Plan must follow Medicare rules. Medicare rules say that CYP testing must be reported with one unit of 
the appropriate CPT code. 
 
We looked at the file and Medicare rules. The requested CYP testing was billed with multiple CPT codes. Per 
the applicable article, this testing must be reported with one unit of the appropriate CPT code and the 
appropriate DEX Z-Code. Based on this information, we decided that Medicare rules for coverage of the 
testing have not been met. Therefore, we decided that the Plan does not have to pay for the CYP panel provided 
on April 29, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for outpatient services provided on February 6, 2020. 
 
You asked the Plan to pay for the outpatient services. You say that you were unaware that this provider is out-
of-network. The Plan denied your request. The Plan says you must receive care from in-network providers with 
the exception of emergency or urgent care, dialysis while temporarily out of the plan's service area or if the 
care cannot be provided with an in-network provider, which requires prior authorization from the plan.  
 
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 outpatient services provided on February 6, 2020.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for Guardant360 testing provided on March 11, 2020. 
 
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. The Plan denied your request. The Plan 
says the denial of payment for this testing is correct, because this testing was not billed with the appropriate 
coding. 
 
The Plan must follow Medicare rules. Medicare rules say that Guardant360 testing must be billed with CPT 
code 81479 for date of service March 11, 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 
Guardant360 testing provided on March 11, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the medical services provided on February 3, 2020 by an out 
of network (OON) provider. 
 
You asked the Plan to pay for the assisted living facility visit.. You say that it is the assisted living facility's job 
to obtain authorization. The Plan denied your request. The Plan says unauthorized, non-plan care is not 
covered. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The requested provider in this case is not a network provider with the Plan. The Plan has network providers 
available who could have provided 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 February 3, 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 testing provided on April 9, 2020. 
 
You asked the Plan to pay for the testing. The Plan denied your request. The Plan says the services were billed 
incorrectly. 
 
The Plan must follow Medicare rules. Medicare rules say that Guardant360 testing must be reported with one 
unit of CPT 81479 and the appropriate DEX Z-Code.  
 
We looked at the file and Medicare rules. The requested Guardant360 testing was billed with multiple CPT 
codes. Per the applicable article, this testing must be reported with CPT 81479 and the appropriate DEX Z-
Code. Based on this information, we decided that Medicare rules for coverage of the testing have not been met. 
Therefore, we decided that the Plan does not have to pay for the Guardant360 testing provided on April 9, 
2020.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the medical services provided on December 12, 2019 by an 
out of network (OON) provider. 
 
You asked the Plan to pay for the radiology services. You say that these services were medically necessary and 
you had a referral. The Plan denied your request. The Plan says unauthorized, non-plan care is not covered. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The provider in this case is not a network provider with the Plan. The Plan had network providers available 
who can provide the items/services at issue in this appeal. The Plan did not pre-approve the item/service at 
issue. In regard to the referral that you reference, the documentation shows that a referral was requested, but 
there is no evidence that the referral was approved.  Furthermore, on the referral request, there is no evidence 
that this patient was referred to this specific out-of-network facility for these services. 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 December 12, 2019 by an out of network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the Guardant360 testing provided on April 6, 2020. 
 
You asked the Plan to pay for the testing. The Plan denied your request. The Plan says the services were billed 
incorrectly. 
 
The Plan must follow Medicare rules. Medicare rules say that Guardant360 testing must be reported with one 
unit of CPT 81479 and the appropriate DEX Z-Code.  
 
We looked at the file and Medicare rules. The requested Guardant360 testing was billed with multiple CPT 
codes. Per the applicable article, this testing must be reported with CPT 81479 and the appropriate DEX Z-
Code. Based on this information, we decided that Medicare rules for coverage of the testing have not been met. 
 Therefore, we decided that the Plan does not have to pay for the Guardant360 testing provided on April 6, 
2020.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for laparoscopy, surgical; repair initial inguinal hernia (CPT 
Code 49650) provided on January 22, 2020 by an out-of-network provider. 
 
You asked the Plan to pay for the services. You say that you come from Thailand and this is the first time for 
you in the hospital in this country. You state you the day you got in the hospital you did not know you have to 
call your primary care physician first. The Plan denied your request. The Plan says you were seen by an out-of-
network provider for an elective surgical repair. The Plan states you do not have out-of-network benefits. 
 
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 laparoscopy, surgical; repair initial inguinal hernia 
(CPT Code 49650) provided on January 22, 2020 by an out-of-network provider.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the Guardant360 panel rendered on March 11, 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 11, 2020.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the CYP panel provided on June 23, 2019. 
 
You asked the Plan to pay for the CYP panel. The Plan denied your request. The Plan says the services were 
billed incorrectly. 
 
The Plan must follow Medicare rules. Medicare rules say that CYP testing must be reported with one unit of 
the appropriate CPT code. 
 
We looked at the file and Medicare rules. The requested CYP testing was billed with multiple CPT codes. Per 
the applicable article, this testing must be reported with one unit of the appropriate CPT code and the 
appropriate DEX Z-Code. Based on this information, we decided that Medicare rules for coverage of the 
testing have not been met. Therefore, we decided that the Plan does not have to pay for the CYP panel provided 
on June 23, 2019.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ambulance services on April 21, 2020. 
 
You asked the Plan to pay for the ambulance services. You say that because of Covid risk you opted to be safe 
and did not get transported. 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 21, 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 on April 21, 2020.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the Guardant360 testing provided on April 21, 2020. 
 
You asked the Plan to pay for the testing. The Plan denied your request. The Plan says the services were billed 
incorrectly. 
 
The Plan must follow Medicare rules. Medicare rules say that Guardant360 testing must be reported with one 
unit of CPT 81479 and the appropriate DEX Z-Code.  
 
We looked at the file and Medicare rules. The requested Guardant360 testing was billed with multiple CPT 
codes. Per the applicable article, this testing must be reported with CPT 81479 and the appropriate DEX Z-
Code. Based on this information, we decided that Medicare rules for coverage of the testing have not been met. 
 Therefore, we decided that the Plan does not have to pay for the Guardant360 testing provided on April 21, 
2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve crowns (D2740) for tooth #'s 8 & 9 and scaling in 
presence of generalized moderate or severe gingival inflammation (D4346). 
 
You asked the Plan to pre-approve the crowns and scaling. You say that you are not able to eat currently 
because of the condition your teeth are in. The Plan denied your request. The Plan says tooth #'s 8 & 9 show 
any major decay or fracture. The Plan also says that there is no evidence that calculus is visible on 50% of the 
teeth. 
 
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. The Plan covers the crowns 
and scaling when the services are medically necessary and reasonable.  
 
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 crowns and scaling. Our reviewer 
says that the crowns for tooth #'s 8 & 9 do not meet the Plan's criteria for coverage, and the scaling in presence 
of generalized moderate or severe gingival inflammation is not medically necessary. Our physician reviewer 
found there does not appear to be any defect in the current crown on #9, and no replacement crown would be 
allowable even with a noted defect if there is a current endodontic problem.  Tooth #8 does not show any 
significant structural damage on the provided x-ray. Our reviewer found that tooth #8 does not meet criteria for 
the amount of structural damage required to meet the criteria, and tooth #9 does not show clear defects to the 
existing crown and appears to have a recurrent endodontic infection. Our physician reviewer also found that the 
scaling in presence of generalized moderate or severe gingival inflammation (D4346) is not supported by the 
record by radiographic, photographic or narrative evidence. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
the Plan's rules for coverage of the crowns and scaling have not been met. Therefore, we decided that the Plan 
does not have to pre-approve crowns (D2740) for tooth #'s 8 & 9 and scaling in presence of generalized 
moderate or severe gingival inflammation (D4346).
Appeal type: Inpatient Hospital
Decision: Favorable

 
We decided that the Plan has to pay for inpatient hospital care from March 8, 2020 through March 10, 2020. 
 
You asked the Plan to pay for acute 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. 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 review has determined that the record showed that at the time of inpatient admission the 
admitting physician reasonably expected that the patient's necessary hospital care (including earlier emergency 
department (ED) and/or observation care) would span two midnights. 
 
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 inpatient hospital care from March 8, 2020 through March 10, 2020.  
 
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.