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

 
We decided that the Plan does not have to pay for a Guardant360 CDx genetic test (0242U) billed for date of 
service February 9, 2022. 
 
You asked the Plan to pay for genetic testing. You say that you have provided medical records to support the 
service billed. The Plan denied your request. The Plan says rules for payment have not been met because the 
genetic testing at issue was billed with the incorrect date of service.  
The Plan must follow Medicare rules. Medicare rules say that the DOS of the test/service must be the date the 
specimen was collected. 
 
We looked at the file and Medicare rules. The available medical documentation indicates that the date of 
service of the specimen collection for the genetic testing at issue has not been reported correctly on the claim. 
Criteria for an exception to the rule have not been met because it does not appear the specimen was collected 
during a hospital outpatient encounter. 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 a 
Guardant360 CDx genetic test (0242U) billed for date of service February 9, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the genetic testing provided on March 17, 2022, billed with 
codes 81225, 81227, 81230, 81231, 81232, 81306, 81335, 81355, 0031U, 0032U and 0033U. 
 
You asked the Plan to pay for the genetic testing billed. You say that these services were reasonable and 
necessary. The Plan denied your request. The Plan says these services were not billed in accordance with 
Medicare rules. 
 
The Plan must follow Medicare rules. The rules say that if one laboratory procedure evaluates multiple genes 
using a next generation sequencing (NGS) procedure, the laboratory shall report only one unit of service of one 
genomic sequencing procedure, molecular multianalyte assay, multianalyte assay with algorithmic analysis, or 
proprietary laboratory analysis code. 
 
We looked at the file and Medicare rules. This was an NGS panel that was not billed with a single panel code 
as required. Based on this information, we decided that Medicare rules for coverage of the genetic testing billed 
have not been met. Therefore, we decided that the Plan does not have to pay for the genetic testing provided on March 17, 2022, billed with codes 81225, 81227, 81230, 81231, 81232, 81306, 81335, 81355, 0031U, 0032U 
and 0033U.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit provided on March 18, 2022, by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for an office visit. You say that you are requesting reconsideration stating 
authorization was not obtained since the member had the services in the nursing home and the appellant is 
requesting reconsideration to have the denied claim reprocessed for payment. The Plan denied your request. 
The Plan says the provider is out-of-network, and it was determined these services can be received in-network. 
 
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 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 an office visit provided on March 18, 2022, by an 
out-of-network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the brace provided on May 24, 2021. 
 
You asked the Plan to pay for the provided service. You say that you were not responsible for choosing the 
provider of the brace. The Plan denied your request. The Plan says providers must be approved or certified by 
Medicare. 
 
The Plan must follow Medicare rules. The rules say that Medicare payment cannot be made to a provider that is 
not enrolled in the Medicare program. 
 
We looked at the file and the rules. A review of the file and Medicare records indicates that the provider at 
issue is not enrolled in the Medicare program. Therefore, we decided that the Plan does not have to pay for the 
brace provided on May 24, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for laboratory services (87481, 87491, 87496 and 87500) billed 
for date of service December 7, 2021. 
 
You asked the Plan to pay for laboratory services. You say that these services were ordered by a physician and 
were necessary. The Plan denied your request. The Plan says there is insufficient information in the records 
provided to show that these services were necessary. 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 laboratory services have been met. 
Specifically, no progress notes or medical records from the referring provider were submitted for review. 
Therefore, we decided that the Plan does not have to pay for laboratory services (87481, 87491, 87496 and 
87500) billed for date of service December 7, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the pneumatic compression device (code E0676) provided on 
January 14, 2022. 
 
You asked the Plan to pay for the pneumatic compression device. You say that this device was used for the 
patient during surgery and was requested by the doctor. The Plan denied your request. The Plan says this item 
is not covered. 
 
The Plan must follow Medicare rules. Medicare rules say that a pneumatic compression device that provides 
intermittent limb compression for the purpose of prevention of venous thromboembolism (E0676) is a 
preventive service.  items that are used for a preventive service or function are excluded from coverage.  The 
specific device you provided was done so for the purpose of thromboembolism prevention during surgery, so it 
is not covered. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the pneumatic compression device have not been met. Therefore, we decided that the Plan does not 
have to pay for the pneumatic compression device (code E0676) provided on January 14, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99100 billed for date of service July 19, 
2021. 
 
You asked the Plan to pay for procedure code 99100. You say that this claim was denied incorrectly. The Plan 
denied your request. The Plan says procedure code 99100 is considered bundled and not separately payable. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate procedure code. 
 
We find that procedure code 99100 has a status indicator of B on the Physician Fee Schedule. This means that 
procedure code 99100 is not separately payable. Based on this information, we decided that Medicare rules for coverage of procedure code 99100 have not been met. Therefore, we decided that the Plan does not have to pay 
for procedure code 99100 billed for date of service July 19, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a preventative office visit and a screening Papanicolaou 
smear provided on April 13, 2022, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for a preventative office visit and a screening Papanicolaou smear. You say that at 
the time of the visit, you were not aware that the enrollee had new Plan coverage, which you do not participate 
with. The Plan denied your request. The Plan says this provider is not a network provider with the Plan. The 
Plan also says that they have also determined that these services are not urgent or emergent, nor were they 
approved in advance. 
 
 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 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 a preventative office visit and a screening 
Papanicolaou smear provided on April 13, 2022, by an out-of-network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for laboratory services provided on April 28, 2022, by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for laboratory services. You say that the enrollee does not go there to your 
laboratory, so out-of-network benefits are not being used as the specimens are sent to you by the participating 
provider. The Plan denied your request. The Plan says this provider is not a network provider with the Plan. 
The Plan also says that the services were not referred by a network provider or rendered in an in-network 
facility. 
 
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 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 laboratory services provided on April 28, 2022, by 
an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit provided on March 16, 2022, by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for an office visit. You say that you are unable to obtain the referral due to a short 
time period. The Plan denied your request. The Plan says this provider is not a network provider with the Plan. 
The Plan also says that they have also determined that these services are not urgent or emergent, nor were they 
approved in advance. 
 
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 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 an office visit provided on March 16, 2022, by an 
out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ultrasound (76536) provided on April 5, 2022, by an out-
of-network (OON) provider. 
 
You asked the Plan to pay for the ultrasound. You say that the services were medically necessary. The Plan 
denied your request. The Plan says the services were provided out-of-network and were not approved in 
advance. 
  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 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 ultrasound (76536) provided on April 5, 2022, 
by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code S9328 billed for date of service April 28, 
2022. 
 
You asked the Plan to pay for procedure code S9328. You say that these services were authorized. The Plan 
denied your request. The Plan says the billed code is invalid for Medicare purposes. 
 The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate procedure code. 
 
We find that procedure code S9328 has a Status Indicator of I on the Physician Fee Schedule. This means that 
procedure code S9328 is not valid for Medicare purposes. Based on this information, we decided that Medicare 
rules for coverage of procedure code S9328 have not been met. Therefore, we decided that the Plan does not 
have to pay for procedure code S9328 billed for date of service April 28, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the nursing facility care provided on January 19, 2022, by an 
out-of-network (OON) provider. 
 
You asked the Plan to pay for the nursing facility care. You say that you would like the claim reconsidered for 
payment. The Plan denied your request. The Plan says the rendering provider is an OON provider and there 
was no approved 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 requested provider in this case is not a network provider with the Plan. The Plan had 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 nursing facility care provided on January 19, 
2022, by an out-of-network (OON) provider.
Appeal type: Home Health
Decision: Favorable

 
We decided that the Plan has to pay for the home health services provided from October 14, 2021, to 
November 8, 2021. 
 
You asked the Plan to pay for the home health services. You say that you would like the Plan to reconsider 
their denial of payment. The Plan denied your request. The Plan says that the services are not covered as billed. 
 
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 denied the claim for payment stating that for the final claim, it must 
have at least one visit related revenue code. In this case, the Plan has not provided enough evidence that shows 
the revenue code billed is not correct per Medicare guidelines, or what the provider should have entered as the 
correct revenue code. Therefore, we decided that the Plan has to pay for the home health services provided 
from October 14, 2021, to November 8, 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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the subsequent hospital care (99232) provided on January 20, 
2022. 
 
You asked the Plan to pay for the subsequent hospital care (99232). You say that you would like the Plan to 
reconsider their denial of payment. The Plan denied your request. The Plan says the enrollee enrolled in 
hospice from January 20, 2022, to January 29, 2022. The Plan says, per Medicare guidelines, the provider must 
bill Original Medicare for the services rendered on January 20, 2022. 
 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 date of service at issue in this appeal. Therefore, 
we decided that the Plan does not have to pay for the subsequent hospital care (99232) provided on January 20, 
2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 36000 billed for date of service January 15, 
2022. 
 
You asked the Plan to pay for procedure code 36000. You say that you disagree with the Plan's denial. The 
Plan denied your request. The Plan says procedure code 36000 is considered bundled and not separately 
payable. 
 The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate procedure code. 
 
We find that procedure code 36000 has a status indicator of B on the Physician Fee Schedule. This means that 
procedure code 36000 is not separately payable. Based on this information, we decided that Medicare rules for 
coverage of procedure code 36000 have not been met. Therefore, we decided that the Plan does not have to pay 
for procedure code 36000 billed for date of service January 15, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the office visit provided on May 12, 2022. 
 
You asked the Plan to pay for the office visit. You say that this was the enrollee's first visit. The Plan denied 
your request. The Plan says new patient qualifications are not met. 
 
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 99204 is office or other outpatient visit for the evaluation 
and management of a new patient. We find that CPT code 99204 is not supported. The records show that the 
enrollee received a new patient visit from a provided in the same group practice on April 26, 2022.  Based on this information, we decided that Medicare rules for coverage of the office visit have not been met. 
Therefore, we decided that the Plan does not have to pay for the office visit provided on May 12, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a lower extremity prothesis (L5999). 
 
You asked the Plan to pre-approve a lower extremity prothesis. You say that the services are necessary. The 
Plan denied your request. The Plan says the item cannot be requested separately. 
 
The Plan must follow Medicare rules. Medicare rules say that use of L5999 is incorrect coding (unbundling). 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of a lower extremity prothesis have not been met. Therefore, we decided that the Plan does not have 
to pre-approve a lower extremity prothesis (L5999).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a group 3 power wheelchair with a single power option. 
 
You asked the Plan to pre-approve a group 3 power wheelchair with a single power option. You say that the 
services are necessary. The Plan denied your request. The Plan says based on the documentation provided, 
coverage criteria has not been met. 
 
The Plan follows Medicare rules. Medicare rules say that power mobility devices are covered when specific 
criteria are met. 
 
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 a group 3 power wheelchair with a 
single power option. Our reviewer says that the services are not medically necessary. Our physician reviewer 
found based on the medical records provided there is no documentation that the group 3 power wheelchair with 
a single power option with power tilt at issue in this case meets Medicare/Local Coverage Determination 
(LCD) - Power Mobility Devices - L33789 criteria for medically reasonable and necessary. Provided records 
do not support that the enrollee is high risk for skin breakdown, has a history of pressure ulcer(s) or has had 
skin flap surgery. Records do not document the enrollee performs bladder self-catheterization or that she has 
increased lower extremity muscle tone or spasticity. The enrollee's motor strength is documented as 5/5 in all 
four extremities as of April 26, 2022, with a neurologist's examination. She is reported to be independent with 
grooming, toileting and hygiene. The enrollee appears to meet criteria for a group 3 power wheelchair with no 
power option but not for a group 3 power wheelchair with a single power option with power tilt.  
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of a group 3 power wheelchair with a single power option have not been met. 
Therefore, we decided that the Plan does not have to pre-approve a group 3 power wheelchair with a single 
power option.