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

 
We decided that the Plan does not have to pay for the oncology, gene expression profiling (OO12M) rendered 
by the out-of-network (OON) provider on September 23, 2021. 
 
You asked the Plan to pay for this service. You say that you are requesting a reconsideration of the Plan's 
denial for payment. The Plan denied your request. The Plan says the service was 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 service 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 this service. Therefore, we decided that the Plan 
does not have to pay for the oncology, gene expression profiling (OO12M) rendered by the out-of-network 
(OON) provider on September 23, 2021.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the screening digital breast tomosynthesis, bilateral (77063) 
and the screening mammography, bilateral (77067) rendered by the out-of-network (OON) provider on  
October 19, 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 screening digital breast tomosynthesis, bilateral (77063) and the screening 
mammography, bilateral (77067) rendered by the out-of-network (OON) provider on October 19, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the hereditary cardiovascular panel testing provided on 
August 24, 2021. 
 
You asked the Plan to pay for the testing services. You say that the documentation substantiates the claim. The 
Plan denied your request. The Plan says the testing does not meet coverage criteria. 
 
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 records do not show that the testing was ordered by the enrollees 
treating physician for a specific medical problem. The records do not show the enrollees treating physician 
intended for the lab testing to be provided. It appears that the testing at issue may have been ordered by an 
unsolicited outreach telephone call to the enrollee. Based on this information, we decided that the Medicare 
rules for coverage have not been met. Therefore, we decided that the Plan does not have to pay for the 
hereditary cardiovascular panel testing provided on August 24, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the office visit (99202) provided on January 28, 2021. 
 
You asked the Plan to pay for the office visit. You say that you would like reconsideration based on the records 
submitted. The Plan denied your request. The Plan says there is not an established relationship between the 
enrollee and ordering physician. 
 
The Plan must follow Medicare rules. Medicare rules say that unless provided otherwise, other services 
included on the Medicare telehealth services list must be furnished using, at a minimum, audio and video 
equipment permitting two-way, real-time interactive communication between the patient and distant site 
physician or practitioner. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the office visit have not been met. Specifically, the documentation does not clearly indicate that the 
service was furnished using audio and video equipment permitting two-way, real-time interactive 
communication between the patient and distant site physician or practitioner. CPT code 99202 is not included 
on the list of codes which are appropriate for audio-only telehealth services. The documentation does not 
clearly show if this service was furnished using audio-only or audio-video communication. Therefore, we 
decided that the Plan does not have to pay for the office visit (99202) provided on January 28, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for wound care supplies (A6010, A6220) provided on October 
29, 2021, by an out-of-network provider. 
 
You asked the Plan to pay for wound care supplies. You say that the items at issue were a medical necessity for 
the enrollee. The Plan denied your request. The Plan says rules for payment for out-of-network care have not 
been met. 
 
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 wound care supplies (A6010, A6220) provided on 
October 29, 2021, by an out-of-network provider.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the carpal tunnel surgery (64721) provided on August 19, 
2021. 
 
You asked the Plan to pay for the carpal tunnel surgery (64721). You say that the services should be processed 
and paid. The Plan denied your request. The Plan says services of an assistant surgeon are not covered for this 
procedure. 
 
  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 64721. 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 
carpal tunnel surgery (64721) have not been met. Therefore, we decided that the Plan does not have to pay for 
the carpal tunnel surgery (64721) provided on August 19, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the Guardant360 testing provided on August 17, 2021. 
 
You asked the Plan to pay for the testing services. You say that you were compliant with regulation for billing. 
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. The claim billed a place of service as an independent laboratory. The 
records do not show that the enrollees specimen was obtained at the independent laboratory. Based on this 
information, we decided that Medicare rules for coverage of the testing services have not been met. Therefore, 
we decided that the Plan does not have to pay for the Guardant360 testing provided on August 17, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services rendered on June 8, 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 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. Based on this information, we decided that Medicare rules for 
coverage of these services have not been met. Specifically, this claim was billed with the laboratory POS code. 
The records do not support that the sample was taken in a laboratory setting. Therefore, we decided that the 
Plan does not have to pay for the laboratory services rendered on June 8, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a shoulder orthosis (L3650) provided on November 10, 2021, 
by an out-of-network provider. 
 
You asked the Plan to pay for a shoulder orthosis. You say that the medically necessary item at issue was 
provided to the enrollee in good faith. The Plan denied your request. The Plan says rules for payment for out-
of-network care have not been met. 
 
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 shoulder orthosis (L3650) provided on 
November 10, 2021, by an out-of-network provider.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services rendered on August 4, 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 are not billed correctly. 
 
The Plan must follow Medicare rules. Medicare rules say that 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. Based on this information, we decided that Medicare rules for 
coverage of these services have not been met. Specifically, this claim was billed with the laboratory POS code. 
The records do not support that the sample was taken in a laboratory setting. Therefore, we decided that the 
Plan does not have to pay for the laboratory services rendered on August 4, 2021.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for imaging services provided to the enrollee on November 16, 
2021. 
 
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. 
The Plan says the provider did not bill as required by Medicare coding regulations. 
 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 70450 
is a column II code to column I code 70496. 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 imaging services provided to the enrollee on November 16, 2021.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for imaging services provided to the enrollee on May 2, 2021. 
 
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. 
The Plan says the provider did not bill as required by Medicare coding regulations. 
 
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 70480 is a column II code to column I code 70450. 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 imaging services provided to the enrollee on May 2, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the telehealth services rendered on October 8, 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 procedure code 99442 is not covered. 
 
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 99442 is telephone evaluation and management service 
by a physician or other qualified health care professional who may report evaluation and management services 
provided to an established patient, parent, or guardian not originating from a related E/M service provided 
within the previous 7 days nor leading to an E/M service or procedure within the next 24 hours or soonest 
available appointment; 11-20 minutes of medical discussion. 
 
We find that CPT code 99442 is not supported in the medical record. Specifically, the code was billed within 
seven days of a previous evaluation and management service (99214 billed on October 1, 2020). 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 telehealth services rendered on October 8, 2020.
Appeal type: Testing
Decision: Favorable

 
We decided that the Plan has to waive the copayment for a colorectal cancer screening (G0105) provided on 
November 16, 2021. 
 
You asked the Plan to waive the copayment for the colorectal cancer screening. You say that the services 
should be covered as it was a screening test and you are being billed for diagnostic work. The Plan denied your 
request. The Plan says that the cost-sharing applied correctly based on the services provided 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information. Your 
contract with the Plan says that enrollees will not owe a copayment for Colorectal cancer screening.  
 
The Plan says you must pay a $325 copayment for the colorectal cancer screening. Based on the Plan contract, 
however, you cannot be asked to pay more than a $0 copayment for the colorectal cancer screening. Therefore, 
we decided that the Plan has to waive the copayment for a colorectal cancer screening (G0105) provided on 
November 16, 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: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for a dexamethasone (J1100) and 
methylprednisolone (J1040) injection provided on September 13, 2021. 
 
You asked the Plan to waive the coinsurance for the dexamethasone and methylprednisolone injections. You 
say that the services should be covered. The Plan denied your request. The Plan says the coinsurance applied 
correctly based on the services provided. 
 
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 20% 
coinsurance for Medicare Part B prescription drugs.  
 
 
  You have been asked to pay a 20% coinsurance for the dexamethasone and methylprednisolone injections (total 
allowed is $11.77 x 20% = $2.35). Dexamethasone and methylprednisolone injections fall within the Medicare 
Part B prescription drugs 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 coinsurance for a 
dexamethasone (J1100) and methylprednisolone (J1040) injection provided on September 13, 2021.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for Radiologic examination, chest (71045) provided September 
20, 2021. 
 
You asked the Plan to pay for the diagnostic service. You say that please review attached report that support 
this procedure is not a duplicate and reprocess according to contract. The Plan denied your request. The Plan 
says the claim must be submitted to the primary insurance carrier. 
 
The Plan must follow Medicare rules. The rules state that Medicare plans are considered secondary insurers 
when an enrollee has another type of insurance. This means that the Plan is not responsible for paying for 
services until the claim for those services has gone to the primary insurer.  However, plans are still required to coordinate their benefits with the primary insurers. Plans can coordinate 
their benefits with the primary insurers in three ways. First, the Plan can send the bill directly to the primary 
insurer for payment. Second, the Plan can direct the provider to send the bill to the primary insurer. Third, the 
Plan can pay for the services and submit a bill for reimbursement to the primary insurer. 
 
The Plan has met its obligation with regards to coordination of benefits. Specifically, the Plan has another 
carrier as the primary insurance carrier. As the secondary insurer, the Plan cannot be held responsible for the 
diagnostic service until the primary insurer has denied the claim for these services. Therefore, we decided that 
the Plan does not have to pay for Radiologic examination, chest (71045) provided September 20, 2021.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for skilled nursing facility (SNF) care provided 
from October 1, 2021, to October 15, 2021. 
 
You asked the Plan to waive the copayment for the skilled nursing facility (SNF) care. You say that the 
services should be covered as you went in for an unrelated reason. The Plan denied your request. The Plan says 
the cost-sharing applied correctly based on the services provided, 60 days must past between services for a new 
benefit period to begin. 
 
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 $184 
copayment per day for days 21-100 of Skilled nursing facility (SNF) care.  
 You have been asked to pay a $2,392 copayment for days 21-34 of SNF care ($184 x 13 = $2,392). 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 skilled nursing facility (SNF) care provided from October 1, 2021, to 
October 15, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an emergency room visit and inpatient 
hospital stay provided from May 23, 2021, to May 28, 2021. 
 
You asked the Plan to waive the copayment for the emergency room visit and inpatient hospital stay. You say 
that the services should be covered. The Plan denied your request. The Plan says the cost-sharing applied 
correctly based on the services provided. 
 
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 must pay a $90 
copayment for Emergency care and a $390 copayment per day for days 1-5 of inpatient hospital care. 
 You have been asked to pay a $90 copayment for an emergency room visit and a $1,950 copayment for 5 days 
of inpatient hospital care ($390 x 5 = $1,950 + 90 = $2,040 total). This means that you have been asked to pay 
the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you 
agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the 
copayment for an emergency room visit and inpatient hospital stay provided from May 23, 2021, to May 28, 
2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for home infusion services (99601, 99602) provided on 
September 17, 2020. 
 
You asked the Plan to pay for home infusion services. You say that you have submitted records to support the 
services billed. The Plan denied your request. The Plan says rules for payment have not been 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. 
 
Codes 99601 and 99602 have a status indicator of I on the Physician Fee Schedule. This means that codes 
99601 and 99602 are invalid for Medicare billing purposes. Based on this information, we decided that 
Medicare rules for coverage of home infusion services have not been met. Therefore, we decided that the Plan 
does not have to pay for home infusion services (99601, 99602) provided on September 17, 2020.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the lab services provided on August 4, 2020. 
 
You asked the Plan to pay for the services provided. The Plan denied your request. The Plan says the billed 
codes 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. The claim lists a place of service as an independent laboratory. The records 
do not show that the enrollees sample was taken at the independent laboratory. Based on this information, we 
decided that Medicare rules for coverage of the services provided have not been met. Therefore, we decided 
that the Plan does not have to pay for the lab services provided on August 4, 2020.