Persius/hicric huggingface dataset:
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the vision services provided on January 3, 2020 by an out of 
network (OON) provider. 
 
You asked the Plan to pay for these OON services. You say that you would like the plan to reconsider their 
denial. The Plan denied your request. The Plan says the services rendered are not a covered benefit. 
 
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 vision services provided on January 3, 2020 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 provided on March 2, 2020. 
 
You asked the Plan to pay for lab tests. You say that you are appealing with records. The Plan denied your 
request. The Plan says the denial of payment for these services is correct, because this provider did not perform 
the services billed. 
 
The Plan must follow Medicare rules. Medicare rules say that the provider must furnish to the Plan sufficient 
information to determine whether payment is due.  
 
We looked at the file and Medicare rules. The records submitted include a lab requisition, but do not show that 
this testing was performed by the billing provider. Therefore, you have no furnished sufficient information to 
the Plan to justify payment of the claim as billed. Based on this information, we decided that Medicare rules for 
coverage of lab tests have not been met. Therefore, we decided that the Plan does not have to pay for laboratory 
testing provided on March 2, 2020.
Appeal type: Supplemental Benefit
Decision: Favorable

 
We decided that the Plan has to pay for a hearing aid fitting (V5261) provided October 28, 2019. 
 
You asked the Plan to pay for the hearing aid fitting. You say that the hearing aid fitting was medically 
necessary and a corrected claim was submitted to the health plan already. The Plan denied your request. The 
Plan says that the claim submitted was missing the provider's NPI number. 
 
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 documentation submitted was limited to the Evidence of Coverage, the 
notice of denial of coverage and the provider's appeal letter. No copy of the claim form was submitted to the 
IRE for review. Additionally, the documentation provided by the plan is unclear as to if the claim was denied 
for being paid previously or if there was still no corrected claim submitted. The plan did not provide sufficient 
documentation for review. Therefore, we decided that the Plan has to pay for a hearing aid fitting (V5261) 
provided October 28, 2019.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the 3D-rendering with interpretation and reporting of CT, 
magnetic resonance imaging, or other tomographic modality with image post-processing (76376) provided on 
December 31, 2019. 
 
You asked the Plan to pay for the 3D-rendering with interpretation and reporting. You say that you would like 
this claim paid at the contracted rate. The Plan denied your request. The Plan says this service is not covered 
separately by Medicare if it is contained in the authorized radiologic procedure. 
 
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 76376 is the 3D rendering with interpretation and 
reporting of computed tomography, magnetic resonance imaging, ultrasound, or other tomographic modality 
with image postprocessing under concurrent supervision. 
 
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 pay for the 3D-rendering with interpretation and 
reporting. Our reviewer says that the service does not meet coverage criteria. Our physician reviewer found 
code 76376 is a non-covered benefit, and considered unnecessary if equivalent information obtained from the 
test has already been provided by another procedure, or provided by a standard CT scan without reconstruction. 
 
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 3D-rendering with interpretation and reporting have not been met. 
Therefore, we decided that the Plan does not have to pay for the 3D-rendering with interpretation and reporting 
of CT, magnetic resonance imaging, or other tomographic modality with image post-processing (76376) 
provided on December 31, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the medical services provided on January 13, 2020 by an out 
of network (OON) provider. 
 
You asked the Plan to pay for the medical services. You say that these services were medically necessary. The 
Plan denied your request. The Plan says unauthorized, non-plan care is not covered. 
 
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. 
 
Neither the provider in this case nor the referring provider is 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 medical services provided on 
January 13, 2020 by an out of network (OON) provider.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the skilled nursing facility (SNF) services provided on July 
25, 2019 to July 31, 2019 by an out of network (OON) provider. 
 
You asked the Plan to pay for the SNF services. You say that you originally sent the claim to Medicare because 
you were not aware that the patient had a health plan. The Plan denied your request. The Plan says 
unauthorized, non-plan care is not covered. 
 
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 skilled nursing facility (SNF) services provided on July 25, 
2019 to July 31, 2019 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 August 29, 2019 to 
February 11, 2020 by an out of network (OON) provider. 
 
You asked the Plan to pay for the medical services. You say that during the dates of service, you were in the 
process of becoming a plan provider, so these services should be paid. The Plan denied your request. The Plan 
says unauthorized, non-plan care is not covered. 
 
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. 
 
You were not a network provider with the Plan on the date of service in question. 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 medical services provided on 
August 29, 2019 to February 11, 2020 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 continuous glucose monitor supply allowance provided 
on March 25, 2020. 
 
You asked the Plan to pay for the supply allowance (K0553). You say that the continuous glucose monitor and 
supplies were medically necessary. The Plan denied your request. The Plan says criteria for a continuous 
glucose monitor were not met, therefore supplies are not covered. 
 
The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when there are both a 
physician order, proof of delivery, and medical support.  
 
The record does not contain relevant medical records which support medical necessity for the supplies provided 
in this case. The enrollee is not insulin treated therefore the Medicare coverage criteria for a CGM is not met. 
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 the continuous glucose monitor supply allowance 
provided on March 25, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided on May 18, 2020 by an out of 
network (OON) provider. 
 
You asked the Plan to pay for the medical services. You say that these services were medically necessary. The 
Plan denied your request. The Plan says unauthorized, non-plan care is not covered. 
 
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 medical services provided on May 18, 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 subsequent nursing facility care provided on February 27, 
2020. 
 
You asked the Plan to pay for the subsequent nursing facility care. The Plan denied your request. The Plan says 
the services were provided without the appropriate prior authorization. 
 
The Plan must follow Medicare rules. The rules say that except for emergency and urgently needed services, 
plans are not required to make payments for any services received by enrollees that are not provided directly by 
the Plan or through arrangements made by the Plan. 
 
The services at issue in this appeal were not provided in an emergency or urgent care situation. These services 
were not provided by the Plan or through arrangements with them. Therefore, we decided that the Plan does not 
have to pay for subsequent nursing facility care provided on February 27, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the office visit coded 99203 provided on May 11, 2020. 
 
You asked the Plan to pay for the office visit. You say that you would like the plan to reconsider their denial. 
The Plan denied your request. The Plan says the services billed are not supported by the documentation. 
 
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 99203 is office or other outpatient visit for the evaluation 
and management of a new patient, which requires these 3 key components: A detailed history; A detailed 
examination; Medical decision making of low complexity. Counseling and/or coordination of care with other 
physicians, other qualified health care professionals, or agencies are provided consistent with the nature of the 
problem(s) and the patient's and/or family's needs. Usually, the presenting problem(s) are of moderate severity. 
Typically, 30 minutes are spent face-to-face with the patient and/or family. 
 
We find that CPT code 99203 is not supported in the medical record. Specifically, the documentation supports 
that the enrollee has received face-to-face services by this provider within the past three years. Therefore, the 
billing of a "new patient" office visit is invalid. 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 coded 99203 provided on May 11, 2020.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the skilled nursing facility (SNF) services provided on 
August 1, 2019 to August 4, 2019 by an out of network (OON) provider. 
 
You asked the Plan to pay for the SNF services. You say that you initially submitted this claim to Original 
Medicare, so you were not aware that authorization was needed. The Plan denied your request. The Plan says 
unauthorized, non-plan care is not covered. 
 
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 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 skilled nursing facility (SNF) services 
provided on August 1, 2019 to August 4, 2019 by an out of network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to waive the copayment for a new-patient specialist office visit (99203) 
on May 28, 2020. 
 
You asked the Plan to waive the copayment for a new-patient specialist office visit. You say that you should be 
charged a $0 copayment for routine podiatry care. The Plan denied your request. The Plan says the correct 
copayment was applied. 
 
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 $50 
copayment for each specialist visit for Medicare-covered services.  
 
You have been asked to pay a $50 copayment for a new-patient specialist office visit. A new-patient specialist 
office visit falls within the "Physician/Practitioner services, including doctor?s office visits" 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 copayment for a new-patient specialist office visit (99203) on May 28, 
2020.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the emergency department visit services provided on August 
9, 2018. 
 
You asked the Plan to pay for the emergency department visit services. You say that you would like the plan to 
reconsider their denial. The Plan denied your request. The Plan says the claim was submitted untimely. 
 
The Plan follows Medicare rules. The rules say that claims for services furnished on or after January 1, 2010 
must be filed no later than one calendar year after the date of service. 
 
The record shows that a claim for the emergency department visit services was not filed until December 26, 
2019. This means that more than one calendar year from the date of service had passed before a claim was 
filed. Therefore, we decided that the Plan does not have to pay for the emergency department visit services 
provided on August 9, 2018.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the alveoloplasty in conjunction with extractions provided on 
May 26, 2020. 
 
You asked the Plan to pay for the alveoloplasty. You say that you were in pain and could not wait for treatment 
any longer. You also say that you believe an exception should be made due to the difficulty in getting the 
services right away. The Plan denied your request. The Plan says this service is not a covered benefit. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans 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 
alveoloplasty in conjunction with extractions provided on May 26, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the skilled nursing services provided from November 2, 2019 
to November 13, 2019. 
 
You asked the Plan to pay for the home health skilled nursing services.. You say that the services were 
authorized.  The Plan denied your request. The Plan says the provider submitted the claim without the 
Treatment Authorization Code and you have $0 responsibility until a corrected claim is received. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
We find that CPT code G0299 and Q5001 were not billed correctly. Specifically, the Treatment Authorization 
Code is missing from the claim. Based on this information, we decided that Medicare rules for coverage of the 
home health skilled nursing services have not been met. Therefore, we decided that the Plan does not have to 
pay for the skilled nursing services provided from November 2, 2019 to November 13, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided on February 4, 2020 by an out of network (OON) provider.

You asked the Plan to pay for the office visit (99204). You say that you would like reconsideration because prior authorization was not needed for this service. The Plan denied your request. The Plan says utilization of network providers is required when possible and available.

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 February 4, 2020 by an out of network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for a gene analysis (0033U) provided on August 26, 2019.

You asked the Plan to pay for a gene analysis. You say that the claim should be paid. The Plan denied your request. The Plan says the billed code is not supported.

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 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 pay for a gene analysis. Our physician reviewer found the medical records provided does not include sufficient documentation to verify that additional HTR2A (5-hydroxytryptamine receptor 2A), HTR2C (5-hydroxytryptamine receptor 2C) (eg, citalopram metabolism) gene analysis, common variants (ie, HTR2A rs7997012 [c.614-2211T>C], HTR2C rs3813929 [c.-759C>T] and rs1414334 [c.551-3008C>G]) was performed on August 26, 2019, therefore this service cannot be verified.

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 gene analysis have not been met. Therefore, we decided that the Plan does not have to pay for a gene analysis (0033U) provided on August 26, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for moderate sedation services (99152) provided on December 30, 2019.
You asked the Plan to pay for the moderate sedation services. You say that you would like reconsideration based on the records submitted. The Plan denied your request. The Plan says the documentation submitted did not indicate the presence of an independent trained observer to assist in the monitoring of the member's level of consciousness and physiological status; therefore, the billed service 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 CPT code. In this case, the CPT Code Manual definition of code 99152 is moderate sedation services provided by the same physician or other qualified health care professional performing the diagnostic or therapeutic service that the sedation supports, requiring the presence of an independent trained observer to assist in the monitoring of the patient's level of consciousness and physiological status; initial 15 minutes of intraservice time, patient age 5 years or older. We find that CPT code 99152 is not supported in the record. Specifically, the documentation submitted does not indicate the presence of an independent trained observer to assist in the monitoring of the patient's level of consciousness and physiological status. Based on this information, we decided that Medicare rules for coverage of the moderate sedation services have not been met. Therefore, we decided that the Plan does not have to pay for moderate sedation services (99152) provided on December 30, 2019.