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

 
We decided that the Plan does not have to pay for principal care management services provided on June 1, 
2022, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for principal care management services. You say that you would like to request 
reconsideration of the denied claim. The Plan denied your request. The Plan says the provider is out-of-network 
and authorization is required prior to an out-of-network visit. 
 
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 principal care management services provided on 
June 1, 2022, by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an epidural steroid injection for the enrollee. 
 
You asked the Plan to pre-approve the injection. You say that this is medically necessary. The Plan denied your 
request. The Plan says the records do not show concordant history, physical and radiologic imaging to support 
lumbar radiculopathy.  
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 injection. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found that in this case, the records do not show the enrollee has a concordant history, physical, and radiological 
imaging to support lumbar radiculopathy. The review has determined the history, physical exam, and imaging 
do not support a covered diagnosis for this injection. The pain has not endured for four weeks, despite 
conservative care. The symptoms are not enough to greatly impact quality of life or function. The review has 
determined that the requested ESI is not medically reasonable or necessary. 
 
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 injection have not been met. Therefore, we decided that the Plan does not 
have to pre-approve an epidural steroid injection for the enrollee.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the genetic testing provided on December 6, 2021, billed 
with codes 81120, 81121, 81206, 81210, 81292, 81295, 81298, 81301, 81317, and 81194. 
 
You asked the Plan to pay for the genetic testing billed. You say that this was medically necessary. The Plan 
denied your request. The Plan says this was not billed correctly. 
 
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 
December 6, 2021, billed with codes 81120, 81121, 81206, 81210, 81292, 81295, 81298, 81301, 81317, and 
81194.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for home health services provided from September 7, 2021, to 
October 23, 2021. 
 
You asked the Plan to pay for home health services. You say that this should be covered. The Plan denied your 
request. The Plan says this was provided by a private company that does not bill insurance. 
 
The Plan must follow Medicare rules. The rules say that Medicare payment cannot be made to a provider that is 
not enrolled in the Medicare program. 
 
Review of the file and Medicare records indicates that the provider at issue is not enrolled in the Medicare 
program. Therefore, we decided that the Plan does not have to pay for home health services provided from 
September 7, 2021, to October 23, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the office visit (99202) provided on May 20, 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 (99202) provided on May 20, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99497 billed for date of service October 15, 
2021. 
 
You asked the Plan to pay for procedure code 99497. You say that you believe this service is separately 
payable. The Plan denied your request. The Plan says payment for code 99497 is bundled into payment for 
code 99223. 
 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 99497 
is a column II code to column I code 99223. This claim has not been billed with an appropriate modifier to 
bypass the edit. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we 
decided that the Plan does not have to pay for procedure code 99497 billed for date of service October 15, 
2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an unlisted procedure of the nervous system provided to the 
enrollee on February 25, 2022. 
 
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. 
The Plan says there is invalid modifier/procedure use in this case. 
 
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 64999 is [*****enter CPT Codebook definition*****]. 
 
We asked our coder 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 services. Our reviewer says that the services at issue in 
this case were not supported by the medical records. Our reviewer found that the medical records did not 
indicate the correct use of procedure code 64999 with the modifier -59. 
 
We looked at this coder'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 pay for an unlisted procedure of the nervous system provided to the enrollee on February 25, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an outpatient office visit provided on June 3, 2022, by an 
out-of-network (OON) provider. 
 
You asked the Plan to pay for an outpatient office visit. You say that you are requesting a review for 
reconsideration of payment. The Plan denied your request. The Plan says no authorization was obtained prior to 
office visit. 
 
  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 outpatient office visit provided on June 3, 2022, 
by an out-of-network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a pneumatic compression device provided to the enrollee 
from January 20, 2022, to February 16, 2022. 
 
You asked the Plan to pay for the device. You say that this should be paid for. The Plan denied your request. 
The Plan says payment for this service would have been included under the facility claim. 
 
The Plan must follow Medicare rules. The rules say that all items and non-physician services furnished to 
inpatients must be furnished directly by the hospital or billed through the hospital under arrangements. 
 
It is not appropriate to bill this device separately when it rendered to a hospital inpatient. Based on this 
information, we decided that Medicare rules for coverage of the device have not been met. Therefore, we 
decided that the Plan does not have to pay for a pneumatic compression device provided to the enrollee from 
January 20, 2022, to February 16, 2022.
Appeal type: Hospice
Decision: Unfavorable

 
We decided that the Plan does not have to pay for medical services provided on February 10, 2022. 
 
You asked the Plan to pay for the medical services. You say that you timely filed this claim so it should be 
paid. You said that these services were medically necessary and provided in good faith. The Plan denied your 
request. The Plan says the enrollee was on hospice on the date of service in question, so either the hospice or 
Original Medicare is responsible for this claim. 
 
Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice 
services. Medicare hospice pays for claims related to the terminal illness. The rules say that the Plan may direct 
the provider to bill Medicare directly for these services.   
The enrollee was under the Medicare hospice benefit for the dates of service at issue in this appeal. Therefore, 
we decided that the Plan does not have to pay for medical services provided on February 10, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the genetic testing provided on June 8, 2021, billed with 
codes 81432, 81437, 81201, 81317, 81404, 81405, 81406, and 81479. 
 
You asked the Plan to pay for genetic testing. You say that this was medically necessary. The Plan denied your 
request. The Plan says this was not billed correctly. 
 
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 genetic testing have not been met. Therefore, we decided that the Plan does not have to pay for the genetic testing provided on June 8, 
2021, billed with codes 81432, 81437, 81201, 81317, 81404, 81405, 81406, and 81479.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for code 11103 billed for date of service November 10, 2021. 
 
You asked the Plan to pay for code 11103. You say that you would like this code reconsidered. The Plan 
denied your request. The Plan says you have not provided medical records to support the billing of this service. 
 
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. In this case, you have not provided any medical records to support payment of 
this claim, despite the fact that the Plan has sent you six separate requests for these records.  Without these 
records, we cannot determine if this claim is payable. 
 
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 code 11103 billed for date of service November 10, 2021. have been met. Therefore, we decided that the Plan does not have to pay for code 11103 
billed for date of service November 10, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the Psychiatric diagnostic evaluation (90791) provided on 
June 9, 2022. 
 
You asked the Plan to pay for the Psychiatric diagnostic evaluation. 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 
when provided by a licensed professional counselor (LPC). 
 
The Plan must follow Medicare rules. The rules say that Medicare payment cannot be made to a provider that is 
not enrolled in the Medicare program. The rules also say that a licensed professional counselor is not eligible to 
enroll in Medicare. 
 
Review of the file and Medicare records indicates that the provider at issue is not enrolled in the Medicare 
program. Therefore, we decided that the Plan does not have to pay for the Psychiatric diagnostic evaluation 
(90791) provided on June 9, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the observation discharge services provided on March 7, 
2022, billed with code 99217. 
 
You asked the Plan to pay for the services as billed. You say that the records support payment for this code. 
The Plan denied your request. The Plan says this same provider was already reimbursed for code 99236. These 
two codes cannot be paid on the same date to the same provider. 
 
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 99217 
is a column II code to column I code 99236 with a modifier indicator of 0. The column II code is therefore not payable. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we decided that 
the Plan does not have to pay for the observation discharge services provided on March 7, 2022, billed with 
code 99217.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an assessment of and care planning for a patient with 
cognitive impairment provided on April 14, 2022, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for an assessment of and care planning for a patient with cognitive impairment. You 
say that you would like to request reconsideration of the denied claim. The Plan denied your request. The Plan 
says the provider is out-of-network and authorization is required prior to an out-of-network visit. 
 
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 assessment of and care planning for a patient 
with cognitive impairment provided on April 14, 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 psychiatric evaluation with medical services provided on 
March 7, 2022, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for a psychiatric evaluation with medical services. You say that you treated the 
patient in good faith that the facility had already checked Plan coverage. The Plan denied your request. The 
Plan says no authorization was obtained prior to psychiatric evaluation with medical 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 a psychiatric evaluation with medical services 
provided on March 7, 2022, by an out-of-network (OON) provider.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for services (99204, 73610 and 73630) provided on March 16, 
2022. 
 
You asked the Plan to pay for provider services. You say that these services were necessary and are supported 
as billed. The Plan denied your request. The Plan says no medical records were included in this appeal to show 
that the services at issue were reported correctly and were medically necessary. 
 
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 have been met. Specifically, the information provided does not include any medical records to support the necessity of these services and that 
these services were provided as reported. Therefore, we decided that the Plan does not have to pay for services 
(99204, 73610 and 73630) provided on March 16, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an outpatient hospital clinic visit provided on October 15, 
2021, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for an outpatient hospital clinic visit. You say that you disagree with the denial of a 
claim payment for services rendered on October 15, 2021. The Plan denied your request. The Plan says an 
authorization was not obtained prior to physician visit. 
 
  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 outpatient hospital clinic visit provided on 
October 15, 2021, by an out-of-network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services (84480, 80053, 80061, 82043, 82306, 
82550, 82570, 82607, 83036, 83090, 84439, 84443, 84481, 85025, 86141, and G0483) provided on December 
8, 2021. 
 
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 payment for code 84480 is bundled into 
payment for code 84481. Additionally, you billed with an incorrect place of service on the 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 84480 
is a column II code to column I code 84481 with a modifier indicator of 0. The column II code is therefore not 
payable.  
 
Medicare rules also 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 laboratory 
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. Based on the claim submitted, Medicare billing 
criteria have not been met. Therefore, we decided that the Plan does not have to pay for the laboratory services 
(84480, 80053, 80061, 82043, 82306, 82550, 82570, 82607, 83036, 83090, 84439, 84443, 84481, 85025, 
86141, and G0483) provided on December 8, 2021.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Intracept procedure for the enrollee. 
 
You asked the Plan to pre-approve the services. You say that this is medically necessary. The Plan denied your 
request. The Plan says unproven and not medically necessary procedures are not covered by Medicare due to 
insufficient evidence of efficacy. 
 
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 services. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found that this procedure is experimental. More research is needed. 
 
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 the Intracept procedure for the enrollee.