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

 
We decided that the Plan does not have to waive the copayment for lab services you received on August 31, 
2021. 
 
You asked the Plan to waive the copayment for the lab services. You say that you did not know that your 
provider would order labs and you were not fasting on the day of your visit.  You said that you had to make a 
separate visit for labs, so you should not have to pay this copayment. The Plan denied your request. The Plan 
says you were charged this copayment correctly. The Plan says that you would have been assessed a 
copayment even if the labs had occurred on the day of your office visit because your provider sent the 
specimen to a different facility for processing. 
 
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 $10 
copayment for lab tests.  
 
You have been asked to pay a $10 copayment for the lab services. This copayment applies regardless of when 
you receive the lab testing. 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 lab services you received 
on August 31, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. You say that the requested admission to an IRF is medically 
necessary. The Plan denied your request. The Plan says the requested admission to an IRF does not meet 
criteria. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 
 
 
 
 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 IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found the enrollees medical conditions are stable with no issues that require a physicians 
evaluation three or more times per week. The enrollee will not be able to fully participate in and benefit from 
the intensive rehabilitation therapy program provided in an inpatient rehabilitation facility due to his level of 
weakness, persistent mental status impairment and poor endurance. Care at the skilled nursing facility level 
appears to be appropriate in this case. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the emergency anesthesia (99140) provided on May 20, 
2021. 
 
You asked the Plan to pay for the emergency anesthesia. You say that you would like reconsideration based on 
the records submitted. The Plan denied your request. The Plan says CPT code 99140 has a status indicator of B. 
 
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 99140 is not supported in the record. Specifically, CPT code 99140 has a status 
indicator of B. This means that the payment for CPT code 99140 is always bundled into another procedure or 
service. Based on this information, we decided that Medicare rules for coverage of the emergency anesthesia 
have not been met. Therefore, we decided that the Plan does not have to pay for the emergency anesthesia 
(99140) provided on May 20, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the visit with a gastroenterologist you had 
on June 13, 2021. 
 
You asked the Plan to waive the copayment for the gastroenterology visit. You say that this charge is invalid 
because the doctor saw you while you were in the hospital. The Plan denied your request. The Plan says you 
were not an inpatient on the date of service, so this copayment was charged correctly. The Plan says you were 
in an outpatient status, so this copayment can apply. 
 
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 $40 
copayment for visits with a specialist.  
 
You have been asked to pay a $40 copayment for the gastroenterology visit. The gastroenterology visit falls 
within the visits with a specialist benefit category. Your contract explicitly states that this copayment applies to 
services that include medical care furnished in a hospital outpatient department. You were an outpatient at the 
time of these 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 visit with a gastroenterologist you had on June 13, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the anesthesia services (01922) rendered by the out-of-
network (OON) provider on August 2, 2021. 
 
You asked the Plan to pay for these services. You say that you are requesting a reconsideration of the Plan's 
denial for payment. The Plan denied your request. The Plan says the services were 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 had network providers available 
who could have provided the services at issue in this appeal. The Plan did not pre-approve the services at issue. We found no exception that would require the Plan to pay for these services. Therefore, we decided that the 
Plan does not have to pay for the anesthesia services (01922) rendered by the out-of-network (OON) provider 
on August 2, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the Guardant360 testing provided on May 6, 2021. 
 
You asked the Plan to pay for the testing services. You say that the codes are not on the physician fee schedule. 
The Plan denied your request. The Plan says the billed code cannot be verified. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate code. We looked at the file and the rules. If an independent lab bills for services, the place where the sample was 
taken is reported as the POS. We find that the testing at issue was billed with a place of service at indicates an 
independent laboratory. The records do not show that the sample was taken at an independent laboratory. 
Based on this information, we decided that Medicare rules for coverage have not been met. Therefore, we 
decided that the Plan does not have to pay for the Guardant360 testing provided on May 6, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the services provided by an out-of-network provider on 
August 25, 2021. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the services were not 
authorized. 
 
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 had network providers available who could have provided the services at issue in this appeal. The 
Plan did not pre-approve the services at issue. We found no exception that would require the Plan to pay for 
these services. Therefore, we decided that the Plan does not have to pay for the services provided by an out-of-
network provider on August 25, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the comprehensive genomic profiling testing provided on 
July 29, 2021. 
 
You asked the Plan to pay for the testing services. You say that the test results were needed to help determine 
the course of treatment for the enrollee. The Plan denied your request. The Plan says the testing was not 
medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 We looked at the file, and Medicare rules. The testing at issue is unlikely to impact therapeutic decision 
making. Based on this information, we decided that Medicare rules for coverage have not been met. Therefore, 
we decided that the Plan does not have to pay for the comprehensive genomic profiling testing provided on 
July 29, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the genetic testing provided on September 27, 2021. 
 
You asked the Plan to pay for the testing. The Plan denied your request. The Plan says this is not a covered 
screening test. The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few 
tests listed in the Medicare rules section, are not covered. 
 
The testing at issue in this appeal was requested solely for screening purposes. Medicare does not cover this 
testing solely for screening purposes. Therefore, we decided that the Plan does not have to pay for the genetic 
testing provided on September 27, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for post-root canal supplies and services provided on August 9, 
2021. 
 
You asked the Plan to pay for post-root canal supplies and services. You say that the services at issue should be 
covered under your supplemental benefit. The Plan denied your request. The Plan says rules for payment have 
not been met because you have not provided proof of payment for the services at issue. 
 
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 post-root canal supplies and services 
have not been met. Specifically, the case record does not contain proof of payment in full for the services at 
issue. Therefore, we decided that the Plan does not have to pay for post-root canal supplies and services 
provided on August 9, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services. 
 
You asked the Plan to pre-approve the LTACH services. You say that the requested admission to a LTACH is 
medically necessary. The Plan denied your request. The Plan says the requested admission to a LTACH does 
not meet criteria. 
 
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 pre-approve 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 the enrollee appears to be improving and should only require short-term additional 
acute care services that can be safely administered at the current facility. There are no services at the LTACH 
that the enrollee requires that are not already available and covered at the current facility. Transfer to a lower 
level of care may be considered when treatment has completed. 
 
 
 We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve long term acute care hospital (LTACH) services.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the services (99153) provided on June 7, 2021. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says this code is not 
payable. 
 
The Plan must follow Medicare rules. Medicare rules say that the OPPS recognizes that CPT code 99153 is a 
practice expense (PE) only code and is not paid to the physician in the facility setting.  
 
We find that payment for CPT code 99153 is not supported. Specifically, there is no separate payment for CPT 
code 99153 for services provided in the facility setting. Therefore, we decided that the Plan does not have to 
pay for the services (99153) provided on June 7, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the intravenous (IV) vitamin services (A9152) provided on 
August 12, 2021, through September 14, 2021. 
 
You asked the Plan to pay for the IV vitamin services. You say that you would like reconsideration because 
these infusions have been greatly helping your condition. The Plan denied your request. The Plan says the is 
not a Medicare covered benefit. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly.  
 
 
 
 
 
 We find that CPT code A9152 is not supported in the record. Specifically, this service is not a Medicare 
covered benefit. Therefore, we decided that the Plan does not have to pay for the intravenous (IV) vitamin 
services (A9152) provided on August 12, 2021, through September 14, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the Guardant360 molecular diagnostic panel provided on 
July 23, 2021. 
 
You asked the Plan to pay for the Guardant360 testing. You say that you believe that the POS rules being cited 
only apply to services paid on the Physician Fee Schedule and not the Clinical Laboratory Fee Schedule 
(CLFS). You state that the contractor for your jurisdiction allows these services to be billed with POS code 81 
for all CLFS services. The Plan denied your request. The Plan says this was billed with the incorrect POS code 
as the sample was taken in the hospital setting. 
 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 file clearly shows that this sample was taken in the outpatient 
hospital setting, meaning that POS code 22 would be appropriate. Please note that we have reviewed the POS 
code citation and find that it is not exclusively applicable only to Physician Fee Schedule services. 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 molecular diagnostic panel 
provided on July 23, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the lab services provided on September 15, 2021. 
 
You asked the Plan to pay for the lab services. You say that the tests were ordered for a better evaluation of the 
enrollee's condition. The Plan denied your request. The Plan says the screening testing is not a Medicare 
benefit. 
 The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few 
tests listed in the Medicare rules section, are not covered. 
 
We looked at the file and the rules. The lab services were requested solely for screening purposes. Testing 
without signs or symptoms of a medical problem or condition are not a covered benefit. Medicare does not 
cover the testing at issue for screening purposes. Therefore, we decided that the Plan does not have to pay for 
the lab services provided on September 15, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pay for the outpatient office visit (99202) infectious agent detection by nucleic acid (DNA or RNA) (87426) Infectious agent antigen detection by immunoassay technique (87426) Specimen collection for severe acute respiratory syndrome coronavirus 2 (sars-cov-2) (coronavirus disease [covid-19]) (G2023) provided September 9, 2021.  You asked the Plan to pay for the outpatient services. You say that there is no other EOB to provide. This should have been paid accordingly. You request the denied claim be reconsidered for payment coverage. The Plan denied your request. The Plan says the explanation of benefits from the primary insurance carrier is needed before this claim can be considered.  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, there is another insurance provider that is the primary carrier. As the secondary insurer, the Plan cannot be held responsible for the outpatient services until the primary insurer has denied the claim for these services. Therefore, we decided that the Plan does not have to pay for the outpatient office visit (99202) infectious agent detection by nucleic acid (DNA or RNA) (87426) Infectious agent antigen detection by immunoassay technique (87426) Specimen collection for severe acute respiratory syndrome coronavirus 2 (sars-cov-2) (coronavirus disease [covid-19]) (G2023) provided September 9, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the deluxe eyeglass frames (V2025) and disposable contact 
lenses (S0500) provided on December 22, 2020. 
 
You asked the Plan to pay for the eyeglass frames and disposable contacts. You say that another provider took 
away your 2020 allowance from you, and you would like the items/services you received on December 22, 
2020, to be paid. The Plan denied your request. The Plan says they have opened a separate grievance into your 
issue; however, at this time payment cannot be approved for the services in question. You previously exhausted 
your 2020 benefit for routine eyewear. 
 
Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine 
vision and eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in 
this case. The Plan covers these services up to $200 once per calendar year. 
 
We looked at the file and the Plan's rules. The record shows that you previously used your benefit on October 
19, 2020. Based on this information, we decided that the Plan's rules for coverage of the eyeglass frames and 
disposable contacts have not been met. Therefore, we decided that the Plan does not have to pay for the deluxe 
eyeglass frames (V2025) and disposable contact lenses (S0500) provided on December 22, 2020.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for home health services (99601, 99602) provided June 9, 2021. 
 
You asked the Plan to pay for the home health services. You say that the services were medically necessary. 
The Plan denied your request. The Plan says the codes billed cannot be paid. 
 
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 codes 99601, & 99602 are not supported in the medical record. Specifically, per the National 
Physician Fee Schedule, these codes have a status of "I" and are not valid for Medicare purposes. Based on this 
information, we decided that Medicare rules for coverage of the home health services have not been met. 
Therefore, we decided that the Plan does not have to pay for home health services (99601, 99602) provided 
June 9, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for eye refractions (92015) provided on October 26, 2021 by an 
out-of-network (OON) provider. 
 
You asked the Plan to pay for the eye refractions. You say that this service was medically necessary. The Plan 
denied your request. The Plan says this service is only covered when performed by plan contract 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 had network providers 
available who could have provided the services 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 these services. Therefore, we decided 
that the Plan does not have to pay for eye refractions (92015) provided on October 26, 2021 by an out-of-
network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the lab services provided on July 19, 2021. 
 
You asked the Plan to pay for the lab services. The Plan denied your request. The Plan says these services are 
not payable. 
 
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 lab services provided on July 19, 2021.