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

 
We decided that the Plan does not have to pay for the mass spectrometry (83789) provided on August 3, 2021. 
 
You asked the Plan to pay for the mass spectrometry (83789). You say that the attached documentation should 
be reviewed as the lab test yielded inconsistent results. The Plan denied your request. The Plan says the place 
of service code must reflect the location of the patient when the specimen was obtained.  The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. Medicare rules say that the Place of Service 
(POS) code is generally used to reflect the actual setting where the beneficiary receives the face to-face service. 
 
In this case, the CPT Code Manual definition of code 83789 is mass spectrometry and tandem mass 
spectrometry (eg, MS, MS/MS, MALDI, MS-TOF, QTOF), non-drug analyte(s) not elsewhere specified, 
qualitative or quantitative, each specimen. 
 
We find that CPT code 83789 is not supported in the medical record. Specifically, the claim was billed with an 
incorrect POS code. Based on this information, we decided that Medicare rules for coverage of the mass 
spectrometry (83789) have not been met. Therefore, we decided that the Plan does not have to pay for the mass 
spectrometry (83789) provided on August 3, 2021.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the Radiologic examination (72110) provided on July 30, 
2021. 
 
You asked the Plan to pay for code 72110. You say that you would like the Plan to reconsider their denial of 
payment. The Plan denied your request. The Plan says the services are not covered as billed.  
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 72110 
is a column II code to column I code 72082. This claim has not been billed with an appropriate modifier to 
bypass the edit. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we 
decided that the Plan does not have to pay for the Radiologic examination (72110) provided on July 30, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services provided on February 26, 2021. 
 
You asked the Plan to pay for the laboratory services. You say that you would like the Plan to reconsider their 
denial of payment. The Plan denied your request. The Plan says the services are not covered as billed. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
 
We looked at the file and Medicare rules. In this case, the claim was billed with an incorrect place of service 
(POS) code per Medicare guidelines. The records show that the specimen was obtained in an office setting. Therefore, we decided that the Plan does not have to pay for the laboratory services provided on February 26, 
2021.
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 
from July 16, 2021, to July 31, 2021. 
 
You asked the Plan to pay for the LTACH services. You say that the services were medically necessary. The 
Plan denied your request. The Plan says the services were not medically necessary. 
 
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. Our physician 
reviewer found provided documentation does not indicate medical necessity for admission to a LTACH. The 
reviewer found that the enrollee is receiving appropriate care at the present acute care hospital. The reviewer 
found that the enrollee does not require services at the LTACH that are not available at the acute care hospital 
where he is currently receiving care. There are no services available at the LTACH that the enrollee requires 
that are not available at the health care setting being offered by the health plan. Therefore, the reviewer found 
that the LTACH services are not medically necessary, reasonable, and appropriate for the diagnosis and 
condition of the enrollee and able to be furnished safely and effectively only on an inpatient basis. 
 
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. Specifically, the file shows that the 
enrollee does not require services at the LTACH that are not available at the acute care hospital where he is 
currently receiving care. Therefore, we decided that the Plan does not have to pay for long term acute care 
hospital (LTACH) services provided from July 16, 2021, to July 31, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services rendered on July 18, 2021. 
 
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 lab testing generally must be ordered by a 
physician who has furnished a consultation or treats an enrollee for a specific medical problem.  
 
 
 
 
 We looked at the file and Medicare rules. The file does not contain documentation of an established 
relationship between the enrollee and the ordering provider. Without a record showing that this provider is 
treating the enrollee, the criteria for coverage of this testing have not been met. Therefore, we decided that the 
Plan does not have to pay for the laboratory services rendered on July 18, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the hospital discharge day management (99238) provided on 
January 12, 2021. 
  You asked the Plan to pay for the hospital discharge day management (99238). You say that the patient's 
medical records warrant the service of more than one physician with distinct specialties as reasonable and 
necessary. You say that the medical records should be reviewed, and the claim reconsidered for payment. The 
Plan denied your request. The Plan says an appropriate modifier was not billed with this code edit. 
 
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 99238 
is a column II code to column I code 99223. This claim has not been billed with an appropriate modifier to 
bypass the edit. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we 
decided that the Plan does not have to pay for the hospital discharge day management (99238) provided on 
January 12, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services provided on March 5, 2021. 
 
You asked the Plan to pay for the laboratory services. You say that you would like the Plan to reconsider their 
denial of payment. The Plan denied your request. The Plan says the services are not covered as billed. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
 
We looked at the file and Medicare rules. In this case, the claim was billed with an incorrect place of service 
(POS) code per Medicare guidelines. The records show that the specimen was obtained in an office setting. Therefore, we decided that the Plan does not have to pay for the laboratory services provided on March 5, 
2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the definitive drug testing provided on May 12, 2021. 
 
You asked the Plan to pay for the definitive drug testing. You say that these services were medically necessary 
and should be paid. The Plan denied your request. The Plan says this was not billed with the proper POS code. 
 
The Plan must follow Medicare rules. Medicare rules say that for lab services, the POS code must reflect the 
location in which the sample was taken. POS code 81 is used to describe samples taken by the laboratory 
directly. The Plan must follow Medicare rules. Medicare rules say that for lab services, the POS code must reflect the 
location in which the sample was taken. POS code 81 is used to describe samples taken by the laboratory 
directly. Therefore, we decided that the Plan does not have to pay for the definitive drug testing provided on 
May 12, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the medical services (80076, 93000, and J8499) provided on 
May 19, 2021. 
 
You asked the Plan to pay for the medical services. You say that you would like the Plan to reconsider their 
denial of payment. The Plan denied your request. The Plan says the services are not covered. 
 
The Plan must follow Medicare rules. Medicare rules say that the provider, supplier, or beneficiary, as 
appropriate, must furnish to the intermediary or carrier sufficient information to determine whether payment is 
due and the amount of payment. 
 
We looked at the file and Medicare rules. Based on this information, we decided that there is insufficient information in the record to determine if Medicare rules for coverage of the medical services (80076, 93000, 
and J8499) provided on May 19, 2021, have been met. Therefore, we decided that the Plan does not have to 
pay for the medical services (80076, 93000, and J8499) provided on May 19, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services provided on August 12, 2021. 
 
You asked the Plan to pay for the laboratory services. You say that you would like the Plan to reconsider their 
denial of payment. The Plan denied your request. The Plan says the services are not covered as billed. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
 
We looked at the file and Medicare rules. In this case, the claim was billed with an incorrect place of service 
(POS) code per Medicare guidelines. The records show that the specimen was obtained in an off-campus outpatient hospital setting. Therefore, we decided that the Plan does not have to pay for the laboratory services 
provided on August 12, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services rendered on May 26, 2021. 
 
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 services were not billed correctly. 
 
The Plan must follow Medicare rules. Medicare rules say that claims must be billed with the correct place of 
service (POS) code. 
 
 
 
 
 We looked at the file and Medicare rules. The claim for these services was billed with POS code 81 for a 
laboratory setting; however, the file shows that the specimen was obtained in an office setting and should have 
been billed with POS code 11. Therefore, we decided that the Plan does not have to pay for the laboratory 
services rendered on May 26, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services provided on July 16, 2021. 
 
You asked the Plan to pay for the laboratory services. You say that you would like the Plan to reconsider their 
denial of payment. The Plan denied your request. The Plan says the services are not covered as billed. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
 
We looked at the file and Medicare rules. In this case, the claim was billed with an incorrect place of service (POS) code per Medicare guidelines. The records show that the specimen was obtained in an office setting. 
Therefore, we decided that the Plan does not have to pay for the laboratory services provided on July 16, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the office visit provided by an out-of-network provider on 
August 9, 2021. 
 
  You asked the Plan to pay for the out-of-network office visit. You say that the doctor was not responsible to 
obtain authorization since the patient was in the hospital. You say that the claim should be reviewed and 
processed for reimbursement. The Plan denied your request. The Plan says out-of-network services were not 
approved. 
 
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 
item/service at issue and there are no records to support the enrollee was in the hospital at the time of the visit. 
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 office visit provided by an out-of-network provider on August 9, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the introduction of catheter into dialysis circuit (36902) 
provided on October 23, 2021. 
 
You asked the Plan to pay for the introduction of catheter into dialysis circuit (36902). You say that the 
surgical assistant had no choice to not be on the case and ethically could not deny the services to the patient. 
You say that the documentation should be reviewed, and the claim processed for full reimbursement of the 
charges. The Plan denied your request. The Plan says multiple physicians/assistants are not covered. 
 
  The Plan follows Medicare rules. Medicare rules state that for codes with an assistant at surgery indicator of 1, 
assistant surgeon services are not covered. In this case, you billed assistant surgery services for Current 
Procedural Terminology (CPT) code 36902. The Medicare Fee Schedule Database contains a surgical indicator 
of 1 for this procedure. This means that Medicare has determined that an assistant surgeon is not medically 
necessary and will not be paid. Based upon this information, we find that Medicare coverage criteria for the 
introduction of catheter into dialysis circuit (36902) have not been met. Therefore, we decided that the Plan 
does not have to pay for the introduction of catheter into dialysis circuit (36902) provided on October 23, 2021.
Appeal type: Imaging
Decision: Favorable

 
We decided that the Plan has to waive the out of network rates for a heart ultrasound (code 93306) provided on 
July 26, 2021. 
 
You asked the Plan to waive the out of network rates for a heart ultrasound. You say that the enrollee was on 
vacation and needed medical attention. You also say that this was a medical emergency, and out of network 
should not apply. The Plan denied your request. The Plan says that the enrollee was stabilized and the out of 
network cost sharing applied. The Plan says that the enrollee has been charged the correct cost sharing amount. 
 
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and 
diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or 
payment. 
 
The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their 
decision to deny your request. The Plan did not submit medical records showing the enrollees condition was 
not, or was no longer, an emergency. Therefore, the Plan cannot cover the service at the out of network rate. 
 
 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 enrollees contract with the Plan says that the doctors who give 
you emergency care are the ones who decide when you are stable, and the medical emergency is over. The 
contract also says that enrollees must pay a $200 copayment per day, for days 1-5, for in-network inpatient 
hospital care. 
 
The Plan says the enrollee must pay 30% coinsurance for a heart ultrasound as part of an out of network 
hospital stay. Based on the plan contract, however, the enrollee cannot be asked to pay more than the in-
network inpatient per day copayment, which includes the cost for a heart ultrasound. Therefore, a heart 
ultrasound is not subject to a separate out of network coinsurance. We decided that the Plan has to waive the 
out of network rates for a heart ultrasound (code 93306) provided on July 26, 2021.  
 
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: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the Guardant360 testing provided on June 20, 2021. 
 
You asked the Plan to pay for the Guardant360 testing. You say that you feel that the POS rules cited by the 
Plan only apply to lab tests paid on the Physician Fee Schedule (PFS) and that using POS 81 is correct for this 
testing. The Plan denied your request. The Plan says this was not billed with the proper POS code based on 
where the services took place. 
 The Plan must follow Medicare rules. Medicare rules say that for lab services, the POS code must reflect the 
location in which the sample was taken. POS code 81 is used to describe samples taken by the laboratory 
directly. 
 
We looked at the file and Medicare rules. The documentation does not indicate this sample was taken by the 
lab directly. As such, the use of POS code 81 is not supported. 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 June 20, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the Guardant360 testing provided on May 24, 2021. 
 
You asked the Plan to pay for the Guardant360 testing. You say that you feel that the POS rules cited by the 
Plan only apply to lab tests paid on the Physician Fee Schedule (PFS) and that using POS 81 is correct for this 
testing. The Plan denied your request. The Plan says this was not billed with the proper POS code based on 
where the services took place. 
 The Plan must follow Medicare rules. Medicare rules say that for lab services, the POS code must reflect the 
location in which the sample was taken. POS code 81 is used to describe samples taken by the laboratory 
directly. 
 
The Plan must follow Medicare rules. Medicare rules say that for lab services, the POS code must reflect the 
location in which the sample was taken. POS code 81 is used to describe samples taken by the laboratory 
directly. 
 
We looked at the file and Medicare rules. The documentation does not indicate this sample was taken by the 
lab directly. As such, the use of POS code 81 is not supported. Based on this information, we decided that 
Medicare rules for coverage of the Guardant360 testing have not been met. Therefore, we decided that the Plan 
does not have to pay for the Guardant360 testing provided on May 24, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services provided on August 9, 2021. 
 
You asked the Plan to pay for the laboratory services. You say that you would like the Plan to reconsider their 
denial of payment. The Plan denied your request. The Plan says the services are not covered. 
 
The Plan must follow Medicare rules. Medicare rules state that routine ESRD lab services are not separately 
payable. Labs should bill the facility directly for lab services as they are considered part of the composite rate. 
No other payment for these services is allowed. Therefore, we decided that the Plan does not have to pay for 
the laboratory services provided on August 9, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the Guardant360 CDx panel provided on September 9, 2021. 
 
You asked the Plan to pay for the Guardant360 CDx panel. You say that you feel that the POS rules cited by 
the Plan only apply to lab tests paid on the Physician Fee Schedule (PFS) and that using POS 81 is correct for 
this testing. The Plan denied your request. The Plan says this was not billed with the proper POS code based on 
where the services took place. 
 The Plan must follow Medicare rules. Medicare rules say that for lab services, the POS code must reflect the 
location in which the sample was taken. POS code 81 is used to describe samples taken by the laboratory 
directly. 
 
We looked at the file and Medicare rules. The documentation does not indicate this sample was taken by the 
lab directly. As such, the use of POS code 81 is not supported. 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 CDx panel provided on September 9, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a specialist telehealth visit provided on 
September 21, 2021. 
 
You asked the Plan to waive the copayment for the specialist telehealth visit. You say that you feel that the call 
was only to schedule a scan and no consultation was performed. 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 $45 
copayment for each telehealth visit with a specialist.  
 
The file shows that recent history, lab work, and medications were reviewed during the visit. Therefore, you 
have been asked to pay a $45 copayment for the specialist telehealth visit. The specialist telehealth visit falls within the Physician/Practitioner Services, Including Doctor's Office Visits 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 a specialist telehealth visit provided on September 21, 2021.