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

We decided that the Plan does not have to pay for an office visit (99213) provided on August 24, 2021, by an
out-of-network (OON) provider.
You asked the Plan to pay for an office visit. You say that prior authorization is not required for an office visit.
The Plan denied your request. The Plan says the unauthorized services rendered were by a non-participating
provider. The Plan also says that it was determined that the services received were not urgent/emergent, and the
member does not have out of network coverage for services determined to be non-urgent/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 (99213) provided on August 24,
2021, by an out-of-network (OON) provider.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pay for skilled nursing facility (SNF) services provided to the 
enrollee from August 1, 2020, to August 14, 2020. 
 
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 the payment integrity post-service, post-payment Patient Driven Payment Model (PDPM) 
clinical validation audit found that the  provider has reported skilled services with the incorrect PDPM Health 
Insurance Prospective Payment System (HIPPS) Score. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate code. 
 
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 the available documentation does not 
support that supervision of oral hygiene was the enrollee's usual functional ability. The enrollee has his own 
teeth, and ulcer/rashes is checked. 
 
 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 skilled nursing facility (SNF) services provided to the enrollee from August 1, 2020, to August 
14, 2020.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Ingrezza 80 mg capsule. 
 
You asked the Plan to pre-approve Ingrezza. You say that this is medically necessary for the enrollee's 
condition. The Plan denied your request. The Plan says this drug is not covered under the enrollee's medical 
benefit. 
 
 
 
 
 
 
 The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-
administered drugs. The self-administered drugs requested here are not among the types which are covered by 
Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve Ingrezza 80 mg capsule.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the biopsy of a lesion in the mouth (D7410) provided 
September 24, 2021 
 
You asked the Plan to pay for the biopsy of a lesion in the mouth. You say that this service was needed to 
evaluate for cancer. The Plan denied your request. The Plan says this service is not covered because it was not 
medically necessary. 
 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 Plan covers the biopsy of 
a lesion in the mouth when the services are medically necessary and reasonable.  
 
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 biopsy of a lesion in the mouth. Our 
reviewer says that the biopsy of a lesion in the mouth was not medically necessary. Our physician reviewer 
found that the lesion has been present since 2016 and is unchanged according to the supplied records. There has 
been no reported change in size, color, or texture of the growth. The lesion has already been followed for over 
5 years with no apparent changes. The removal of what has been deemed a benign lesion (Code D7410) was 
reasonable if it were a bother to the enrollee however it was not medically necessary as there has been no 
indication of the lesion being malignant or likely to undergo malignant changes. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
the Plan's rules for coverage of the biopsy of a lesion in the mouth have not been met. Therefore, we decided 
that the Plan does not have to pay for the biopsy of a lesion in the mouth (D7410) provided September 24, 2021
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services (CPT code 0242U) provided on July 
27, 2021. 
 
You asked the Plan to pay for the laboratory services. You say that the claim should be paid. The Plan denied 
your request. The Plan says the service is not covered as billed. 
 
The Plan must follow Medicare rules. 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. CPT code 0242U (1 
Unit) remains not supported. The place of service on the CMS-1500 form line 24B must reflect the location of 
the patient when the specimen was obtained. The submitted claim form indicates the laboratory specimen was 
obtained in a laboratory, POS 81; however, the submitted medical documentation and/or claim history indicates 
that the specimen was obtained in an outpatient hospital POS 22. Also, the submitted medical records reflect a 
different date of service than the billed date of service, the date of service is the date the specimen was 
collected. Of note, the patient resides in North Carolina and the billing laboratory is located in California; 
therefore, the billed code, the validity and accuracy of the claim cannot be verified. It is noted multiple attempts 
were made to obtain additional information from the provider. Therefore, we decided that the Plan does not 
have to pay for the laboratory services (CPT code 0242U) provided on July 27, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the deductible for an orthovisc injection provided on June 14, 2021.
You asked the Plan to waive the deductible for the orthovisc injection and a specialist office visit. You say that the cost-sharing should be covered as you thought you would only pay $20. The Plan denied your request. The Plan says the cost-sharing applied correctly.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information. Your contract with the Plan says that there is a $4,900 out of pocket maximum and a $20 copayment which applies to Medicare Part B prescription drugs and Outpatient diagnostic tests and therapeutic services and supplies.
The item or service you asked the Plan to waive the deductible for falls within the benefit category Medicare Part B prescription drugs and Outpatient diagnostic tests and therapeutic services and supplies. The Plan has followed Medicare rules by clearly disclosing in the contract that there is a $4,900 out of pocket maximum and a $20 copayment which applies to Medicare Part B prescription drugs and Outpatient diagnostic tests and therapeutic services and supplies. This cost sharing is a contractual obligation that had not been met at the time the orthovisc injection and a specialist office visit was received on June 14, 2021. Therefore, we decided that the Plan does not have to waive the deductible for an orthovisc injection and the copayment for a specialist office visit provided on June 14, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for immunization services provided to the enrollee on June 2, 
2021. 
 
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 this was correctly reimbursed by Part D. 
 
In the absence of injury or direct exposure to illness, Medicare does not pay for or provide the services. The 
Plan follows the same rules.  
 
Records do not show that you have been injured or directly exposed to any illness related to the services. 
Therefore, we decided that the Plan does not have to pay for immunization services provided to the enrollee on 
June 2, 2021.  
 
 
 
 Benefits for the services may be available under Medicare Part D. Contact the Plan that administers Part D 
benefits for further information concerning any benefits and appeal rights.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for Selective catheter placement, arterial system; abdominal, 
pelvic or lower extremity artery branch (36247) provided September 2, 2021. 
 You asked the Plan to pay for the catheter placement. You say that the enrollee had multiple exams on this date 
of service. Attached reports to support level of service. Please reconsider for processing. The Plan denied your 
request. The Plan says duplicate claim to a previously processed 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 find that CPT code 36247 is not supported in the medical record. Specifically, the submitted 
documentation supports 1 unit each of 36247 which was previously approved and paid. Based on this 
information, we decided that Medicare rules for coverage of the catheter placement have not been met. 
Therefore, we decided that the Plan does not have to pay for Selective catheter placement, arterial system; 
abdominal, pelvic or lower extremity artery branch (36247) provided September 2, 2021.
Appeal type: Hospice
Decision: Unfavorable

We decided that the Plan does not have to pay for physician's services provided on April 29, 2021.
You asked the Plan to pay for physician's services. The Plan denied your request. The Plan says Original Medicare would be responsible for payment of all Medicare covered services related or unrelated to the member's terminal condition. The Medicare hospice benefit, through fee-for-service Medicare, covers all hospice care from the effective date of election to the date of discharge or revocation. During the election, fee-for-service Medicare also covers attending physician services and all care unrelated to the terminal illness until the first day of the month following the month in which hospice was revoked or discharged.
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 physician's services provided on April 29, 2021.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the services (76776) provided on July 23, 2021. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says this is a bundled 
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. In this case, we have confirmed that code 93976 
is a column II code to column I code 76776. 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 the services (76776) provided on July 23, 2021.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve treatment with Botox (J0585). 
 
You asked the Plan to pre-approve Botox. You say that the requested treatment is a medical necessity for the 
enrollee. The Plan denied your request. The Plan says rules for coverage have not been met. 
 
The Plan must follow Medicare rules. Medicare rules say that, in order to be eligible for coverage under Part B, 
drugs/biologicals must represent an expense to the rendering physician and be included in the physician's bill. 
 
In this case, we have confirmed that the requested medication will be dispensed by a pharmacy and will be 
brought to the office for administration. Since the medication does not represent an expense to the physician 
and will not be included in the physician's bill, it is not eligible for Part B coverage. Therefore, we decided that 
the Plan does not have to pre-approve treatment with Botox (J0585).  
 
Benefits for Botox may be available under Medicare Part D. Contact the Plan that administers Part D benefits 
for further information concerning any benefits and appeal rights.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for surgical assistant services provided to the enrollee from 
March 11, 2021, to March 16, 2021. 
 
You asked the Plan to pay for the services. You say that the services provided were supported. The Plan denied 
your request. The Plan says an assistant surgeon is not covered for this procedure. 
 
The Plan follows Medicare rules. Medicare rules state that for codes with an assistant at surgery indicator of 1, 
assistant surgeon services are not covered. In this case, you billed assistant surgery services for Current 
Procedural Terminology (CPT) code 43762. The Medicare Fee Schedule Database contains a surgical indicator 
of 1 for this procedure. This means that Medicare has determined that an assistant surgeon is not medically 
necessary and will not be paid. Based upon this information, we find that Medicare coverage criteria for the 
services have not been met. Therefore, we decided that the Plan does not have to pay for surgical assistant 
services provided to the enrollee from March 11, 2021, to March 16, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for an office visit (99213) provided on August 11, 2021, by an
out-of-network (OON) provider.
You asked the Plan to pay for an office visit. You say that prior authorization is not required for an office visit.
The Plan denied your request. The Plan says the unauthorized services rendered were by a non-participating
provider. The Plan also says that it was determined that the services received were not urgent/emergent, and the
member does not have out of network coverage for services determined to be non-urgent/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 (99213) provided on August 11,
2021, by an out-of-network (OON) provider.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for the duplex scan of arterial inflow and venous outflow of abdominal, pelvic, scrotal contents and/or retroperitoneal organs; limited study (CPT code 93976) provided on October 5, 2021.
You asked the Plan to pay for the duplex scan. You say that the enrollee had multiple exams on this date of service. The Plan denied your request. The Plan says the service is not covered as billed.
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 93976 is a column II code to column I code 76856. 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 the duplex scan of arterial inflow and venous outflow of abdominal, pelvic, scrotal contents and/or retroperitoneal organs; limited study (CPT code 93976) provided on October 5, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for an office visit (99203) and a diagnostic anoscopy (46600) provided on August 13, 2021, by an out-of-network (OON) provider.
You asked the Plan to pay for an office visit and a diagnostic anoscopy. You say that you are appealing with supporting records. The Plan denied your request. The Plan says the unauthorized services rendered were by a non-participating provider. The Plan also says that it was determined that the services received were not urgent/emergent, and the member does not have out of network coverage for services determined to be non-urgent/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 (99203) and a diagnostic anoscopy (46600) provided on August 13, 2021, by an out-of-network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Dorsal Root Ganglion (DRG) stimulator. 
 
You asked the Plan to pre-approve a DRG stimulator. You say that the requested DRG stimulator is medically 
necessary. The Plan denied your request. The Plan says the requested DRG stimulator is not medically 
necessary. 
 
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 a DRG stimulator. Our reviewer says 
that the requested DRG stimulator is not medically necessary. Our physician reviewer found the enrollee has 
chronic bilateral knee pain and hand pain. She takes Voltaren, Percocet, Xtampza and oxycodone for pain. She 
had a psychological evaluation which stated: "Frontal lobe and executive function deficit." The psychologist 
appears to have cleared her for a spinal cord stimulator (SCS) even though the request is for a DRG stimulator 
which is considered an experimental device.  She has had radiofrequency ablation (RFA) of the genicular 
nerves without improvement. She has had Right total knee arthroplasty x 2 and apparently has a loose 
prosthesis.  
 Based on the documentation provided for review, the psychological evaluation shows "frontal lobe and 
Executive function deficit." She is NOT a good candidate for any stimulation and certainly, it is very 
questionable whether she can give consent for an experimental/ investigational procedure. Furthermore, she has 
a loose prosthesis. Rather than fixing the prosthesis, the physician proposes to place a DRG stimulator (NOT A 
SCS). The enrollee does not have an evidence-based indication for either a DRG stimulator (which is 
experimental) or for a SCS. The request 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 a DRG stimulator have not been met. Therefore, we decided that the Plan does 
not have to pre-approve a Dorsal Root Ganglion (DRG) stimulator.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the targeted genomic sequence analysis (0037U) rendered by 
the out-of-network (OON) provider on September 29, 2021. 
 
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 the service was 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 service at issue in this appeal. The Plan did not pre-approve the service at issue. We found no exception that would require the Plan to pay for this service. Therefore, we decided that the Plan 
does not have to pay for the targeted genomic sequence analysis (0037U) rendered by the out-of-network 
(OON) provider on September 29, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the comprehensive oral evaluation (D0150), complete series 
of intraoral x-rays (D0210), two prophylaxes (D1110 x2), crown (D2752), and periodic oral evaluation 
(D0120) provided from February 25, 2021, to August 26, 2021 by an out-of-network (OON) provider. 
 
You asked the Plan to pay for the dental services. You say that you have been charged $32 per month for an 
optional dental plan, but evidently you were not entitled to be in this plan. You also say that a Plan 
representative made a mistake by enrolling you in this plan. The Plan denied your request. The Plan says 
services performed by an OON provider are not covered because your healthcare plan does not have OON 
benefits. The Plan also says that you did not contact the Plan prior to the services being rendered to verify 
benefits and provider eligibility. 
 
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, you are responsible for 100% of the 
cost for dental services rendered by an OON provider. Therefore, we decided that the Plan does not have to pay 
for the comprehensive oral evaluation (D0150), complete series of intraoral x-rays (D0210), two prophylaxes 
(D1110 x2), crown (D2752), and periodic oral evaluation (D0120) provided from February 25, 2021, to August 
26, 2021 by an out-of-network (OON) provider.