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

 
We decided that the Plan does not have to pay for subsequent nursing facility care (99309) provided on May 
13, 2020 by an out of network (OON) provider. 
 
You asked the Plan to pay for subsequent nursing facility care. You say that your physician provided medically 
necessary services in good faith. In consideration for the services rendered, your doctor is seeking 
reimbursement. The Plan denied your request. The Plan says enrollee's must receive their medical services 
from an in-network provider with the exception being urgent or emergent services. Non-emergent services with 
non-contracted providers require prior authorization before services being rendered. 
 
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 has network providers 
available who can provide 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 subsequent nursing facility care (99309) provided 
on May 13, 2020 by an out of network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for screening services provided to the enrollee on May 14, 2020. 
 
You asked the Plan to pay for this service. You say that this claim should be paid. The Plan denied your 
request. The Plan says this type of testing is not covered for screening services. 
 
The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few 
tests listed above, are not covered. The test at issue in this appeal was 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 screening services provided to the enrollee on May 14, 2020.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve testing. 
 
You asked the Plan to pre-approve the testing. You say that you would like 
reconsideration because this testing was requested by your doctor for treatment of your conditions. The Plan 
denied your request. The Plan says the use of genetic testing to diagnose or treat psychiatric disorders is not 
recommended by an evidence-based practice parameter or clinical practice guidelines. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
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 testing. 
Our reviewer says that the requested items/services are not considered medically reasonable and necessary in 
this case. Our physician reviewer found the available documentation does not support that you have a diagnosis 
of depression and have failed treatment with at least one medication. 
 
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 testing have not been met. Therefore, we decided 
that the Plan does not have to pre-approve testing.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the physician services provided out of network. 
 
You asked the Plan to pay for this service. You say that this claim should be paid. The Plan denied your 
request. The Plan says the enrollee did not have prior authorization for out of network care. 
 
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 has network providers available who can provide 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 physician services 
provided out of network.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve continuation of SNF care provided from November 27, 
2020, forward. 
 
You asked the Plan to pre-approve the SNF care. You say that the stay is medically necessary. The Plan denied 
your request. The Plan says the last covered day for SNF care was November, 27, 2020. The Plan states they 
did not render a decision within the timeframe. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors 
listed above are met. Custodial care is not covered. 
 
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 SNF care. Our reviewer says that 
daily skilled services are not necessary. Our physician reviewer found there are no identifiable skilled nursing 
service needs. There are no identifiable skilled therapy service needs. The beneficiary does not require skilled 
nursing or therapy services on a daily basis. This beneficiary does not meet severity of illness or intensity of 
service criteria for an inpatient basis in a skilled nursing facility setting. 
 
 
 
 
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 SNF care have not been met. Therefore, we decided that the Plan does not 
have to pre-approve continuation of SNF care provided from November 27, 2020, forward.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a lumbar-sacral orthosis (L0650) provided to the enrollee on 
April 12, 2020. 
 
You asked the Plan to pay for the orthosis. You say that the claim should be paid. The Plan denied your 
request. The Plan says the documentation submitted did not include an itemized shipping/billing invoice to 
indicate the specific supplies, or proof of delivery for the billed date of service. 
 
The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when there are both a 
physician order and proof of delivery.  
 
The record does not contain a valid proof of delivery and relevant medical records which support medical 
necessity for the supplies provided in this case. The documentation submitted did not include an itemized 
shipping/billing invoice to indicate the specific supplies, or proof of delivery for the billed date of service. 
Therefore the billed code cannot be verified.  The record shows that the Plan made several attempts to obtain 
the necessary documentation without success. Therefore, we decided that the Plan does not have to pay for a 
lumbar-sacral orthosis (L0650) provided to the enrollee on April 12, 2020.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Home Health Visits and Related Services (CPT Codes: 
G0162, G0151, G0299). 
 
You asked the Plan to pre-approve the services. You say that the services are necessary. The Plan denied your 
request. The Plan says the services are not necessary. 
 
The Plan must follow Medicare rules. The rules say that HHA services may be covered if it is medically 
necessary for the enrollee to receive skilled nursing or therapy.  
 
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 services. Our physician reviewer 
found the records do not show that skilled nursing (SN) services are required to effectively provide treatment, 
care, and/or services in order to improve the patient's condition, or to establish/perform a maintenance program 
to maintain the patient's condition and/or prevent deterioration. There are no complex wounds, new enteral 
feedings or other SN need. The records do not show that skilled therapy is needed to effectively provide 
treatment, care, and/or services in order to improve the patient's level of function, or to establish/perform a 
maintenance program to maintain the patient's level of function and/or prevent deterioration. As the patient 
does not require skilled therapy or skilled nursing services the patient does not meet the definition of home 
health aide services per Section 50.2 and the request for  home health aide services are not reasonable and 
necessary to the treatment of the patient's illness or injury by the skilled professional staff.  
 
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 services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve Home Health Visits and Related Services (CPT Codes: G0162, G0151, G0299).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for injection of diagnostic or therapeutic substance (eg, 
anesthetic, antispasmodic, opioid, steroid, other solution), not including neurolytic substances, including needle 
or catheter placement, interlaminar epidural or subarachnoid, lumbar or sacral (62323) provided March 10, 
2020. 
 
You asked the Plan to pay for the injection services. You say that you believe that the claim is being denied 
incorrectly and need to be reviewed. Please review the attached documents and issue payment accordingly. The 
Plan denied your request. The Plan says if you go to a provider who is not eligible to participate in Medicare, 
you will be responsible for the full cost of the services you receive. 
 
The Plan must follow Medicare rules. The rules say that no Medicare payment may be made to a beneficiary 
for items or services provided directly by a physician or practitioner who has opted out of the program except 
in cases involving emergencies or urgently needed care. 
 
The services at issue in this appeal were provided in a non-urgent, non-emergent situation by the provider who 
has opted out of the Medicare program. Therefore, we decided that the Plan does not have to pay for injection 
of diagnostic or therapeutic substance (eg, anesthetic, antispasmodic, opioid, steroid, other solution), not 
including neurolytic substances, including needle or catheter placement, interlaminar epidural or subarachnoid, 
lumbar or sacral (62323) provided March 10, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the arthrocentesis provided on July 9, 2020. 
 
You asked the Plan to waive the copayment for the arthrocentesis. You say that this was done at the doctor's 
office. You say that you weren't aware this was an outpatient surgery. The Plan denied your request. The Plan 
says the copayment applied correctly. 
 
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 $270 
copayment for Medicare-covered outpatient surgery in an ambulatory surgical center or hospital outpatient 
facility.  
 
You have been asked to pay a $270 copayment for the arthrocentesis. The arthrocentesis falls within the 
"Outpatient surgery, including services provided at hospital outpatient facilities and ambulatory surgical 
centers" benefit category. The arthrocentesis is considered a surgical procedure that was billed by the hospital. 
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 arthrocentesis provided on July 9, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the surgical extraction (D7210), first 15 minutes of deep 
sedation/general anesthesia (D9222), and each subsequent 15 minute increment of deep sedation/general 
anesthesia (D9223) provided on September 21, 2020. 
 
You asked the Plan to pay for the surgical extraction and deep sedation/general anesthesia services. You say 
that this extraction should be covered because it is not your fault that your tooth had to be extracted this way. 
The Plan denied your request. The Plan says these services are not covered under your benefit plan. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plan's coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the 
surgical extraction (D7210), first 15 minutes of deep sedation/general anesthesia (D9222), and each subsequent 
15 minute increment of deep sedation/general anesthesia (D9223) provided on September 21, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for out of network lab services provided on May 23, 2019. 
 
You asked the Plan to pay for this service. You say that this claim should be paid. The Plan denied your 
request. The Plan says that procedure code 81519 (oncotype DX genetic panel) is not medically necessary for 
the diagnosis code reported of C50.912, malignant neoplasm of left female breast. The Plan says that the 
records show at the time of testing there was documentation of lymph node positive disease. This testing is 
only covered for early stage diagnosed cancer without progression. The records show the enrollee had already 
seen progression prior to this testing. Therefore, Medicare criteria were not met.  
 
The Plan must follow Medicare rules. Medicare has specific coverage criteria for this type of testing. Medicare 
covers this testing for newly diagnosed cancer. Medicare does not cover this testing after there is evidence of 
progression of disease. Based on the records provided, Medicare coverage criteria were not met. Therefore, we 
decided that the Plan does not have to pay for out of network lab services provided on May 23, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for out of network services provided to the enrollee on June 24, 
2020. 
 
You asked the Plan to pay for this service. You say that this claim should be paid. The Plan denied your 
request. The Plan says the enrollee did not have prior authorization for out of network care. 
 
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 has network providers available who can provide 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 out of network services 
provided to the enrollee on June 24, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the non-pneumatic walking boot, prefabricated, off-the-shelf  
(L4387) provided August 20, 2020. 
 
You asked the Plan to pay for the walking boot. You say that you are appealing this denial. The L4387 LT was 
billed with the correct place of service. Please see the enclosed medical notes and reprocess for payment.  The 
Plan denied your request. The Plan says the DME service was billed with the incorrect place of service. 
 
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 looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the walking boot have not been met. Specifically, the item at issue was billed with a Place of 
Service code for an office setting, which is not the place where the item will be used. Per the Medicare Claims 
Processing Manual, Chapter 20, section 10, the place of service for DMEs should indicate or reflect the 
location in which the item is being used. Therefore, we decided that the Plan does not have to pay for the non-
pneumatic walking boot, prefabricated, off-the-shelf  (L4387) provided August 20, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the electrical stimulation therapy provided on June 15, 2020 
by an out of network (OON) provider. 
 
You asked the Plan to pay for OON electrical stimulation therapy. You say that this was medically necessary. 
The Plan denied your request. The Plan says this was 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 has network providers 
available who can provide 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 electrical stimulation therapy provided on June 
15, 2020 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 medical services provided on June 22, 2020 by an out of 
network (OON) provider. 
 
You asked the Plan to pay for [Shorter description of ITEM or SERVICE at issue, e.g. "a power wheelchair"]. 
You say that you disagree with the denial. 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 requested provider in this case is not a network provider with the Plan. The Plan has network providers 
available who can provide 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 medical services provided on June 22, 2020 by 
an out of network (OON) provider.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan does not have to pay for out of network services provided to the enrollee on May 7, 2020.
 
You asked the Plan to pay for this service. You say that this claim should be paid. The Plan denied your 
request. The Plan says the enrollee did not have prior authorization with out of network care.
 
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 has network providers available 
who can provide 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 out of network services provided to the enrollee on May 7, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a MyoPro Motion G Limb orthosis (L8702). 
 
You asked the Plan to pre-approve the orthosis. You say that the claim should be paid. The Plan denied your 
request. The Plan says your records show that the requested item has deluxe features that exceed medically 
reasonable and necessary criteria. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
The Plan must follow Medicare rules. Medicare rules say that services that are not medically necessary are not 
covered. The rules also say that experimental and investigational are not covered. The MyoPro Motion G 
orthosis is considered to be experimental and investigational. 
 
Our reviewer says that the requested item has deluxe features that exceed medically reasonable and necessary 
criteria.  
 
We looked at this review, the file, and Medicare rules. Based on this information, we decided that Medicare 
rules for coverage of the orthosis have not been met. Therefore, we decided that the Plan does not have to pre-
approve a MyoPro Motion G Limb orthosis (L8702).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the medical services provided on June 12, 2020 by an out of 
network (OON) provider. 
 
You asked the Plan to pay for the OON services. You say that you went to the podiatrist recommended by your 
primary care provider and they did not give you the services you required. You went to this OON provider and 
they provided the foot care you needed. The Plan denied your request. The Plan says OON care is only covered 
if it is authorized by the plan or in emergency situations. 
 
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 has network providers 
available who can provide 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 medical services provided on June 12, 2020 by 
an out of network (OON) provider.