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

 
We decided that the Plan does not have to pay for a home health visit provided on August 5, 2021, by an out-
of-network (OON) provider. 
 
You asked the Plan to pay for the home health visit. You say that you are the only provider allowed into the 
facility and you would like the claim reimbursed. The Plan denied your request. The Plan says the rendering 
provider is an OON provider and there was no approved authorization. Also, the service rendered was not 
urgent or emergent. 
 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 home health visit provided on August 5, 2021, 
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 (81161, 81286, 81413, 81414, 81442 and 
81479) billed for date of service October 29, 2021. 
 
You asked the Plan to pay for laboratory services. You say that these services were necessary and were 
reported correctly. The Plan denied your request. The Plan says insufficient information was provided to 
support these services. 
 
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 medical records were submitted to support the services at issue as being medically necessary 
and reported correctly. Therefore, we decided that the Plan does not have to pay for laboratory services (81161, 
81286, 81413, 81414, 81442 and 81479) billed for date of service October 29, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit provided on May 13, 2022, by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for the office visit. You say that the service was rendered to the enrollee after a 
hospitalization, and you would like the claim to be paid. The Plan denied your request. The Plan says the 
rendering provider is an OON provider and there was no approved authorization. Also, the service rendered 
was not urgent or emergent. 
 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 May 13, 2022, by an 
out-of-network (OON) provider.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code S9338 billed for date of service March 31, 
2022. 
 
You asked the Plan to pay for procedure code S9338. You say that you would like the Plan to reconsider their 
denial of payment. 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 S9338 has a Status Indicator of I on the Physician Fee Schedule. This means that 
procedure code S9338 is not valid for Medicare purposes. Based on this information, we decided that Medicare rules for coverage of procedure code S9338 have not been met. Therefore, we decided that the Plan does not 
have to pay for procedure code S9338 billed for date of service March 31, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the nursing facility care provided on February 4, 2022, by an 
out-of-network (OON) provider. 
 
You asked the Plan to pay for the nursing facility care. You say that the service rendered to the enrollee was 
medically necessary and you would like reimbursement for the service rendered. 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 February 4, 
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 testing services (88341, 88342, 88360, 88365 and 
88381) billed for date of service December 10, 2021. 
 You asked the Plan to pay for laboratory services. You say that these services were necessary and are supported 
in the medical record. The Plan denied your request. The Plan says this claim was billed with an incorrect date 
of service. 
 
The Plan must follow Medicare rules. Medicare rules say that generally, laboratory claims should be reported 
with the date of service that the specimen was collected. However, if an exception to this rule is met, the 
appropriate date may be the date the test was performed or, in the case of specimens which were stored for 
more than 30 days, the appropriate date is the date the test was obtained from storage. 
 
We looked at the file and Medicare rules. The record shows that the specimen was collected on August 31, 
2021, received by the laboratory on December 4, 2021, and testing was initiated on December 8, 2021. The test 
was then reported on December 14, 2021. The reported date of December 10, 2021, is not supported by the 
records provided. Based on this information, we decided that Medicare rules for billing laboratory services 
have not been met. Therefore, we decided that the Plan does not have to pay for laboratory testing services 
(88341, 88342, 88360, 88365 and 88381) billed for date of service December 10, 2021.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Imfinzi. 
 
You asked the Plan to pre-approve Imfinzi. You say that the services are necessary. The Plan denied your 
request. The Plan says the plan is not responsible for routine costs associated with a clinical trial.  
The Plan must follow Medicare rules. The rules say that Original Medicare pays for the routine costs of 
qualifying clinical trials. Enrollees in a Medicare plan receive the same coverage for qualifying clinical trials as 
people enrolled in Original Medicare. The Plan must cover only the difference between the cost-sharing in 
Original Medicare and the plan cost-sharing for the same services. 
 
In this case, you asked the Plan to pre-approve Imfinzi as part of a clinical trial. The Plan does not cover 
routine costs associated with qualifying clinical trials. Therefore, we decided that the Plan does not have to pre-
approve Imfinzi.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the office visit (99204) provided on May 25, 2022. 
 
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 this service is not covered under your 
contractual policy or by Medicare. 
 
The Plan must follow Medicare rules. The rules say that the only chiropractic service Medicare covers is 
manual manipulation of the spine to correct a subluxation.  
 
The records show that the service at issue is not manual manipulation of the spine. Therefore, we decided that 
the Plan does not have to pay for the office visit (99204) provided on May 25, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 87150 and 87641 billed for date of service 
September 13, 2021. 
 
You asked the Plan to pay for procedure codes 87150 and 87641. You say that these services are supported in 
the medical record provided. The Plan denied your request. The Plan says payment for codes 87150 and 87641 
is bundled into payment for other services billed on this claim. 
 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 87641 
is a column II code to column I code 87150 and 87150 is a column II code to column I code 87500. These 
services have 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 
procedure codes 87150 and 87641 billed for date of service September 13, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the genetic testing provided on March 2, 2022, billed with 
codes 81162, 81201, 81209, 81218, 81292, 81295, 81298, 81307, 81314, 81317, 81321, 81334, 81351, 81406, 
81437 and 81479. 
 
You asked the Plan to pay for the genetic testing billed. You say that these services were medically necessary. 
The Plan denied your request. The Plan says this claim was 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 2, 2022, billed with codes 81162, 81201, 81209, 81218, 81292, 81295, 81298, 81307, 81314, 81317, 
81321, 81334, 81351, 81406, 81437 and 81479.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services coded 81413, 81414, 81161, 81286, 
81404, 81406, 81407, 81439, and 81442 provided on August 5, 2021. 
 
You asked the Plan to pay for the laboratory services. You say that you disagree with the Plan's denial. The 
Plan denied your request. The Plan says the services billed are not a covered benefit. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly.  The 
rules also explicitly say that screening tests, with the exception of the few tests listed in the Medicare rules 
section, are not covered. 
 
Providers must report services with the appropriate CPT code. In this case, we have confirmed that codes 
81413 and 81414 are column II codes to column I code 81439 with a modifier indicator of 0. The column II 
codes are therefore not payable. Based on the claim submitted, Medicare billing criteria have not been met.  
 
The testing at issue in this appeal coded with codes 81161, 81286, 81404, 81406, 81407, 81439, and 81442 
were requested solely for screening purposes. Medicare does not cover this test solely for screening purposes. 
 
Therefore, we decided that the Plan does not have to pay for the laboratory services coded 81413, 81414, 
81161, 81286, 81404, 81406, 81407, 81439, and 81442 provided on August 5, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code H2023 billed for date of service March 25, 
2022. 
 
You asked the Plan to pay for procedure code H2023. You say that other claims for the same service were paid 
and this claim should be reviewed. 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 H2023 has a Status Indicator of I on the Physician Fee Schedule. This means that 
procedure code H2023 is not valid for Medicare purposes. Based on this information, we decided that Medicare 
rules for coverage of procedure code H2023 have not been met. Therefore, we decided that the Plan does not 
have to pay for procedure code H2023 billed for date of service March 25, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the arthroplasty, glenohumeral joint; total shoulder (23472) 
provided on December 7, 2021. 
 
You asked the Plan to pay for the surgical service. You say that the service was medically necessary. The Plan 
denied your request. The Plan says the claim denied correctly. 
 
The Plan follows Medicare rules. The rules say that Medicare only pays for assistant surgery services when the 
procedure is covered for an assistant and the person who assists the surgery bears the designation of a 
physician, PA, NP, or CNS. 
 
In this case, the record does not show that the provider of the surgical assistant service is a physician, PA, NP, 
or CNS. Medicare only makes payment for surgical assistant services when provided by one of these types of 
practitioners. Therefore, we decided that the Plan does not have to pay for the arthroplasty, glenohumeral joint; 
total shoulder (23472) provided on December 7, 2021.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the surgery services provided on March 4, 2022, by an out-
of-network (OON) provider. 
 
You asked the Plan to pay for the surgery services. You say that you would like the services that were rendered 
to the enrollee to be covered with a retro authorization. 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 surgery services provided on March 4, 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 nursing facility care provided on May 8, 2022, by an out-
of-network (OON) provider. 
 
You asked the Plan to pay for the nursing facility care. You say that you submitted medical records as a 
reference to process the claim. The Plan denied your request. The Plan says the rendering provider is an OON 
provider and there was no referral from an in-network provider or an approved authorization. Also, the service 
rendered was not urgent or emergent. 
 
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 May 8, 2022, 
by an out-of-network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the genetic testing provided on March 11, 2022, billed with 
codes 81225, 81226, 81401, 81406, 81479, 81220, 81227, 81230, 81231, 81232, 81240, 81241, 81247, 81283, 
81291, 81306, 81328, 81335, 81350, 81355, 81381, and 81400. 
 
You asked the Plan to pay for the genetic testing billed. 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. 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 11, 2022, billed with codes 81225, 81226, 81401, 81406, 81479, 81220, 81227, 81230, 81231, 81232, 
81240, 81241, 81247, 81283, 81291, 81306, 81328, 81335, 81350, 81355, 81381, and 81400.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the panel testing services provided on March 3, 2022. 
 
You asked the Plan to pay for the testing services. You say that the treatment sought was medically necessary 
to treat the enrollee. The Plan denied your request. The Plan says one code must be submitted for the panel. 
 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 the pharmacogenetics panel testing was not billed with a single code as required.  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 panel testing services provided on March 3, 2022.
Appeal type: Lab
Decision: Favorable

 
We decided that the Plan has to pay for FoundationOne CDx (F1CDx) testing (0037U) provided on April 12, 
2022. 
 
You asked the Plan to pay for F1CDx testing. You say that this is an FDA-approved test that is covered by 
Medicare. The Plan denied your request. The Plan says that there is a Local Coverage Determination (LCD) 
that indicates that any panel that tests for the FANCC gene is non-covered. Since this panel includes that, the 
denial is correct. 
 
The Plan must follow Medicare rules. Medicare rules say that Medicare nationally covers FDA-approved NGS 
testing, such as the F1CDx panel, when provided for an FDA-approved indication. 
 
We looked at the file and Medicare rules. This testing was provided to a patient with melanoma. The FDA 
approval notice indicates that this panel is approved for melanoma. No other valid denial rationale was 
presented by the Plan. Based on this information, we decided that Medicare rules for coverage of F1CDx 
testing have been met. Therefore, we decided that the Plan has to pay for FoundationOne CDx (F1CDx) testing 
(0037U) provided on April 12, 2022.  
 
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 somatic molecular panel provided on March 25, 2022, 
billed with codes 81455, 81479, 81301, 81479 and 81194. 
 
You asked the Plan to pay for the genetic testing billed. You say that these services are supported in the records 
provided. The Plan denied your request. The Plan says this claim was 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 somatic molecular panel 
provided on March 25, 2022, billed with codes 81455, 81479, 81301, 81479 and 81194.