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

 
We decided that the Plan does not have to pay for the paring or cutting of benign hyperkeratotic lesion 
provided on May 31, 2022, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for the paring or cutting of benign hyperkeratotic lesion. You say that this patient is 
an established patient with you and presented for care on May 31, 2022. You also say that this should follow 
under the continuity of care and a payment should be made. The Plan denied your request. The Plan says there 
is no documentation to show that this member was referred to this non-contracted provider by a contracted 
provider, as well as no indication any attempt was made to obtain prior authorization for the out-of-network 
services. 
 
 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 paring or cutting of benign hyperkeratotic 
lesion provided on May 31, 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 chiropractic manipulative treatment (98941) rendered by 
the out-of-network (OON) provider from February 21, 2022, through April 1, 2022. 
 
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 chiropractic manipulative treatment (98941) rendered by the out-of-network 
(OON) provider from February 21, 2022, through April 1, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services provided on April 6, 2021. 
 
You asked the Plan to pay for the lab services. You say that the medical records support payment. The Plan 
denied your request. The Plan says you billed with an incorrect place of service on the claim. 
 
The Plan must follow Medicare rules. Medicare rules say that, for 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 the lab 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 lab services provided on April 6, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for general book work provided on May 25, 2022, by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for the general blood work. You say that the enrollee had an outside referral. The 
Plan denied your request. The Plan says the rendering provider is an OON provider, and it was confirmed 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 general book work provided on May 25, 2022, by 
an out-of-network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a triamcinolone acetonide injection and an injection of 
medication or other substance into Tenon's capsule provided on March 4, 2022, by an out-of-network (OON) 
provider. 
 
You asked the Plan to pay for a triamcinolone acetonide injection and an injection of medication or other 
substance into Tenon's capsule. You say that this was a medical necessity. The Plan denied your request. The 
Plan says this provider is not a network provider with the Plan. The Plan also says that the services were not 
referred by a network provider or rendered in an in-network facility. The Plan also says that these services were 
not approved in advance.  
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The requested provider in this case is not a network provider with the Plan. The Plan had network providers 
available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the 
item/service at issue. We found no exception that would require the Plan to pay for these items/services. 
Therefore, we decided that the Plan does not have to pay for a triamcinolone acetonide injection and an 
injection of medication or other substance into Tenon's capsule 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 a telephone visit for evaluation and management of home 
care services provided on May 25, 2022, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for telephone evaluation and management services. You say that the provider is 
understaffed, which made it difficult to obtain authorization before the services were rendered to the enrollee. 
You also say that it was not reasonable to advise the enrollee to seek care from an in-network provider due to 
the ongoing COVID-19 crisis. The Plan denied your request. The Plan says the claim was processed correctly. 
The Plan says the enrollee is required to receive care from network providers except for cases involving 
emergencies, urgent care, or pre-approved care. The rendering provider in this case is out-of-network and a 
prior authorization was not requested. The Plan also determined that the services are neither urgent nor 
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 telephone visit for evaluation and management 
of home care services provided on May 25, 2022, by an out-of-network (OON) provider.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 27217 billed for date of service February 25, 
2022. 
 
You asked the Plan to pay for procedure code 27217. You say that you have provided medical records to 
support 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 27217 has a Status Indicator of I on the Physician Fee Schedule. This means that 
procedure code 27217 is not valid for Medicare purposes. Based on this information, we decided that Medicare 
rules for coverage of procedure code 27217 have not been met. Therefore, we decided that the Plan does not 
have to pay for procedure code 27217 billed for date of service February 25, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a pneumatic compression device (E0675). 
 
You asked the Plan to pay for a pneumatic compression device. You say that the water-cooling device you used 
was essential to your recovery to reduce swelling, infection and blood clots. You are convinced that you would 
not have recovered as quickly without it. The Plan denied your request. The Plan says a PCD coded as E0675 
to treat peripheral arterial disease is not eligible for reimbursement. 
 
The Plan follows Medicare rules. The rules state that a PCD that provides intermittent limb compression for the 
purpose of prevention of venous thromboembolism (E0676) is a preventive service. The rules also say that a 
PCD coded as E0675 to treat peripheral arterial disease is not eligible for reimbursement. 
 
We looked at the file and Medicare rules. Based on this information we decided that Medicare rules for 
coverage of the PCD have not been met. Specifically, this item is not a covered benefit of Medicare or the Plan. 
PCDs are not covered for preventions of venous thromboembolism nor for treatment of peripheral artery 
disease, regardless of how they are billed on the claim. Therefore, we decided that the Plan does not have to 
pay for a pneumatic compression device (E0675).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for victrectomy chair provided to the enrollee on May 10, 2022. 
 
You asked the Plan to pay for the chair. You say that you thought you did everything correctly to get this 
equipment. The Plan denied your request. The Plan says this is not considered covered. 
 
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a 
medical purpose.   
 
The item at issue in this appeal does not serve a purpose that is primarily medical in nature. This item is 
available to the general public and would be helpful even to those who are not sick or injured. Therefore, we 
decided that the Plan does not have to pay for victrectomy chair provided to the enrollee on May 10, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services provided on February 5, 2022. 
 
You asked the Plan to pay for the laboratory services. 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 
 
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. 
 
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 the laboratory 
services provided on February 5, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the office visit and tangential biopsy of skin provided on 
March 17, 2022, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for the physician services. You say that the services should be covered. The Plan 
denied your request. The Plan says prior authorization was not obtained before the services were rendered to 
the enrollee. 
 
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 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 office visit and tangential biopsy of skin provided on March 
17, 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 lab testing provided on April 5, 2022, by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for the lab testing. You say that the referring physician is in-network with the Plan. 
The Plan denied your request. The Plan says the referring physician and provider are out-of-network and were 
not approved in advance. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
  The requested provider in this case is not a network provider with the Plan. The Plan had network providers 
available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the 
item/service at issue. We found no exception that would require the Plan to pay for these items/services. 
Therefore, we decided that the Plan does not have to pay for the lab testing provided on April 5, 2022, by an 
out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit provided on January 27, 2022, by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for the office visit. You say that it was medically necessary to treat the enrollee. 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 an office visit provided on January 27, 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 lab testing provided on September 30, 2021. 
 
You asked the Plan to pay for the testing services. The Plan denied your request. The Plan says the services are 
not a covered benefit for the diagnoses listed on the claim. 
 
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. 
 
The file shows that testing for folic acid, Vitamin B-12, and Vitamin D were provided. The tests at issue were 
requested for screening purposes. Medicare does not cover this testing for screening purposes. Therefore, we 
decided that the Plan does not have to pay for the lab testing provided on September 30, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code S9328 billed for date of service January 1, 
2022. 
 
You asked the Plan to pay for procedure code S9328. You say that this is a service code only and should be 
paid. The Plan denied your request. The Plan says the billed code is invalid for Medicare purposes. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate procedure code. 
 
We find that procedure code S9328 has a Status Indicator of I on the Physician Fee Schedule. This means that 
procedure code S9328 is not valid for Medicare purposes. Based on this information, we decided that Medicare 
rules for coverage of procedure code S9328 have not been met. Therefore, we decided that the Plan does not 
have to pay for procedure code S9328 billed for date of service January 1, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for outpatient hospital services provided from June 28, 2021, to 
July 7, 2021. 
 
You asked the Plan to pay for the outpatient hospital services. You say that this claim should be reconsidered 
for payment. The Plan denied your request. The Plan says this claim cannot be paid until the multiple units of 
code G0378 are rectified on the bill. 
 
The Plan must follow Medicare rules. Medicare rules say that for outpatient hospital bills, an Integrated 
Outpatient Code Editor edit of 51 will be generated for any claims reporting more than one unit of code G0378 
per claim.  In this case, you still have multiple units of code G0378 listed on the claim, resulting in a claim that 
cannot be priced.  That is why the Plan's denial is appropriate. We looked at the file and Medicare rules. Based 
on this information, we decided that Medicare rules for coverage of the outpatient hospital services have not 
been met. Therefore, we decided that the Plan does not have to pay for outpatient hospital services provided 
from June 28, 2021, to July 7, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the nursing facility services provided on March 14, 2022, by 
an out-of-network (OON) provider. 
 
You asked the Plan to pay for the nursing facility services. You say that the services provided to the enrollee 
was out of medical necessity and you would like the claim processed for payment. The Plan denied your 
request. The Plan says the rendering provider is an OON provider and there was no approved authorization. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
  The requested provider in this case is not a network provider with the Plan. The Plan had network providers 
available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the 
item/service at issue. We found no exception that would require the Plan to pay for these items/services. 
Therefore, we decided that the Plan does not have to pay for the nursing facility services provided on March 
14, 2022, by an out-of-network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for nitrous oxide inhalation (D9230), therapeutic parental drugs 
(D9612), and deep sedation (D9222), provided by an out-of-network provider on October 5, 2021. 
 
You asked the Plan to pay for nitrous oxide inhalation, therapeutic parental drugs, and deep sedation. You say 
that you needed these services done because of your low pain tolerance. The Plan denied your request. The 
Plan says these services are not covered dental benefits. 
 
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 nitrous 
oxide inhalation (D9230), therapeutic parental drugs (D9612), and deep sedation (D9222), provided by an out-
of-network provider on October 5, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a comprehensive oral evaluation (D0150), panoramic 
imaging (D0330), bitewings (D0274), and a resin-based composite (D2392), provided by an out-of-network 
provider on April 11, 2022, to May 16, 2022. 
 
You asked the Plan to pay for the dental services. You say that you were told that you had dental coverage. The 
Plan denied your request. The Plan says the dental services were received from an out-of-network provider and 
are not covered by your supplemental benefits. 
 
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. 
 
The record shows you received the requested dental services from an out-of-network provider. Though the Plan 
offers a dental benefit in excess of Medicare coverage, the requested items or services are not covered under this benefit when received from an out-of-network provider. Therefore, we decided that the Plan does not have 
to pay for a comprehensive oral evaluation (D0150), panoramic imaging (D0330), bitewings (D0274), and a 
resin-based composite (D2392), provided by an out-of-network provider on April 11, 2022, to May 16, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit provided on April 6, 2022, by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for the office visit. You say that the claim should be paid for an office visit because 
of the enrollee's home address. 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 April 6, 2022, by an 
out-of-network (OON) provider.