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

 
We decided that the Plan does not have to pay for perfusion services (99190, 99190-76, 99191, 99192, 86891, 
P9022) provided February 18, 2022. 
 
You asked the Plan to pay for the perfusion services. You say that this service was medically necessary. The 
Plan denied your request. The Plan says this service is not eligible for separate payment. 
 
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 codes 99190, 99190-76, 99191, 99192, 86891, and P9022 are not supported in the medical 
record. Specifically, the enrollee was an inpatient at the time this service was provided. This service must be 
billed by the inpatient facility. Based on this information, we decided that Medicare rules for coverage of the 
perfusion services have not been met. Therefore, we decided that the Plan does not have to pay for perfusion 
services (99190, 99190-76, 99191, 99192, 86891, P9022) provided February 18, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the general health panel (80050) provided on March 27, 
2021. 
 
You asked the Plan to pay for code 80050. 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 as billed. 
 
The Plan must follow Medicare rules. The rules say that code 80050 (general health panel) is considered a non-
covered code. 
 
You have requested payment for services billed under code 80050. Medicare does not cover or pay for services 
billed under this code. Therefore, we decided that the Plan does not have to pay for the general health panel 
(80050) provided on March 27, 2021.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for domiciliary or rest home visit provided on April 4, 2022, by 
an out-of-network (OON) provider. 
 
You asked the Plan to pay for domiciliary or rest home visit. You say that you are appealing the claim payment 
denial. The Plan denied your request. The Plan says the services were provided out-of-network and were not 
approved in advanced. 
 
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 domiciliary or rest home visit provided on April 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 procedure code 99100 billed for date of service May 17, 
2022. 
 
You asked the Plan to pay for procedure code 99100. You say that this code was billed appropriately and 
should be paid. The Plan denied your request. The Plan says procedure code 99100 is considered bundled and 
not separately payable. 
 
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 99100 has a status indicator of B on the Physician Fee Schedule. This means that procedure code 99100 is not separately payable. Based on this information, we decided that Medicare rules for 
coverage of procedure code 99100 have not been met. Therefore, we decided that the Plan does not have to pay 
for procedure code 99100 billed for date of service May 17, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for eyeglasses provided on March 28, 2022. 
 
You asked the Plan to pay for the eyeglasses. The Plan denied your request. The Plan says the provider is not 
an in-network provider in the provider vision network. 
 
Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine 
vision and eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in 
this case.  
 
 We looked at the file and the Plan's rules. The file shows that the eyeglasses were not provided by a vision 
network provider. Based on this information, we decided that the Plan's rules for coverage of the eyeglasses 
have not been met. Therefore, we decided that the Plan does not have to pay for eyeglasses provided on 
March 28, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve foot orthotics (L3230). 
 
You asked the Plan to pre-approve foot orthotics. You say that the orthotic footwear is medically necessary. 
The Plan denied your request. The Plan says this item is not a covered benefit. 
 
Medicare rules state that supportive devices for the feet (such as orthotics) are only covered for patients with 
diabetic foot disease or for patients who wear a leg brace. The Plan follows these same rules.   
 
Records show that you do not suffer from diabetic foot disease and you do not wear a leg brace. Although 
orthotics may be appropriate for you, neither Medicare nor the Plan provides coverage of orthotics for your 
condition. Therefore, we decided that the Plan does not have to pre-approve foot orthotics (L3230).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the pathology services provided on May 11, 2022, by an out-
of-network (OON) provider. 
 
You asked the Plan to pay for the pathology services. You say that the referring provider sent the specimens to 
your laboratory, and you would like the claim paid. The Plan denied your request. The Plan says the rendering 
and referring providers are both OON providers 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 the pathology services provided on May 11, 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 procedure codes A4259 & A4253 billed for date of service 
October 21, 2021. 
 
You asked the Plan to pay for procedure codes A4259 & A4253. You say that the items were medically 
necessary. The Plan denied your request. The Plan says procedure codes A4259 & A4253 are considered 
bundled and not separately payable. 
 
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 codes A4259 & A4253 have a status indicator of P on the Physician Fee Schedule. This 
means that procedure codes A4259 & A4253 are not separately payable. Based on this information, we decided 
that Medicare rules for coverage have not been met. Therefore, we decided that the Plan does not have to pay 
for procedure codes A4259 & A4253 billed for date of service October 21, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for medical services provided on May 10, 2021. 
 
You asked the Plan to pay for the medical services. You say that the patient originally gave you incorrect 
insurance information.  You said that you submitted the claim as soon as you received corrected information. 
The Plan denied your request. The Plan says you did not file your claim in a timely manner. 
 
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 medical services was not filed until May 27, 2022. 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 medical services provided on May 10, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an out-of-network office visit provided on 
February 17, 2022. 
 
You asked the Plan to waive the copayment for an out-of-network office visit. You say that you have multiple 
types of insurance coverage, and you shouldn't have to pay anything. The Plan denied your request. The Plan 
says the copayment applied is correct. 
 
  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 $40 
copayment for each out-of-network Medicare-covered primary care doctor visit.  
 
You have been asked to pay a $40 copayment for an out-of-network office visit. An out-of-network office visit 
falls within the Physician/Practitioner Services, Including Doctors 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 an out-of-network office visit provided on February 17, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the tetanus vaccine administration you received on April 28, 
2022. 
 
You asked the Plan to pay for the tetanus vaccine administration. You say that you cannot afford this bill and 
you were not told beforehand that it would not be covered. The Plan denied your request. The Plan says the 
tetanus vaccine is not covered under your medical benefits. 
 
In the absence of injury or direct exposure to illness, Medicare does not pay for or provide the tetanus vaccine 
administration. The Plan follows the same rules.  
 
Records do not show that you have been injured or directly exposed to any illness related to the tetanus vaccine 
administration. Therefore, we decided that the Plan does not have to pay for the tetanus vaccine administration 
you received on April 28, 2022.  
 
Benefits for the tetanus vaccine administration 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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for laboratory services provided on April 7, 2022, by an OON 
provider. 
 
You asked the Plan to pay for laboratory services. You say that this is being processed out-of-network, we are 
in-network so please send for processing. The Plan denied your request. The Plan says the out-of-network 
services were not authorized. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
 
 The requested provider in this case is not a network provider with the Plan. The Plan 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 laboratory services provided on April 7, 2022, by 
an OON provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for annual wellness visit provided on March 15, 2022, by an out-
of-network (OON) provider. 
 
You asked the Plan to pay for annual wellness visit. You say that the medical records show medical necessity 
for this service. The Plan denied your request. The Plan says the provider is not contracted with this member's 
health plan. The Plan also says that there is no referral letter. 
 
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 annual wellness visit provided on March 15, 2022, 
by an out-of-network (OON) provider.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to pay for code 99285 billed for date of service April 18, 2022. 
 
You asked the Plan to pay for code 99285. You say that the medical records support the level of care billed. 
The Plan denied your request. The Plan says code 99285 is not supported in the medical record. Instead, code 
99284 is the appropriate code for the services 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, the CPT Code Manual definition of code 99285 is Emergency department visit for the evaluation 
and management of a patient, which requires these 3 key components within the constraints imposed by the 
urgency of the patient's clinical condition and/or mental status: A comprehensive history; A comprehensive 
examination; and Medical decision making of high 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 high 
severity and pose an immediate significant threat to life or physiologic function. 
 
 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 code 99285. Our reviewer says that code 99285 is not 
supported in the medical record. Our reviewer found the patient walked into the Emergency Room and was 
alert and oriented and in no distress per provider and their bleeding was controlled. The patient's wife was 
queried about the incident but is not the historian. Labs and imaging were ordered, and the patient was given a 
Tetanus vaccination. His laceration was repaired, and he was released. The level of medical decision-making 
met the audit criteria of Moderate. The Plan was correct that 99284 was the more appropriate code to use. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of code 99285 have not been met. Therefore, we decided that the Plan does not 
have to pay for code 99285 billed for date of service April 18, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a comprehensive oral evaluation (D0150), intraoral x-rays 
(D0210), and a caries risk assessment (D0603) provided on April 8, 2022. 
 
You asked the Plan to pay for an evaluation, x-rays, and an assessment. You say that you disagree with the 
denial of dental services. The Plan denied your request. The Plan says that your benefit for a comprehensive 
oral evaluation (D0150) and intraoral x-rays (D0210) has already been exhausted. The Plan also says that a 
caries risk assessment (D0603) is not covered by your routine 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, a caries risk assessment is not among 
those covered under this benefit. The record shows your benefit for a comprehensive oral evaluation and 
intraoral x-rays was exhausted on date of service December 9, 2020. Therefore, we decided that the Plan does not have to pay for a comprehensive oral evaluation (D0150), intraoral x-rays (D0210), and a caries risk 
assessment (D0603) provided on April 8, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for nail debridement provided on May 6, 2022, by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for nail debridement. You say that the provider has no prior knowledge of the 
patients he will see when he arrives at the facility. You also say that through an oversight in the assisted living 
facility's staff, no prior authorization was obtained for this visit. The Plan denied your request. The Plan says 
this provider is not a network provider with the Plan. 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 nail debridement provided on May 6, 2022, by an 
out-of-network (OON) provider.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code S9328 billed for date of service February 26, 
2022 to March 25, 2022. 
 
You asked the Plan to pay for procedure code S9328. You say that this is a service code only and not used to 
bill for drugs or equipment. 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 February 26, 2022 to March 25, 2022.
Appeal type: Step-Therapy
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Procrit (CPT code J0885, 96372, 85018).

You asked the Plan to pre-approve the medication. You say that if you do not get the injection it will lower your red blood cells. The Plan denied your request. The Plan says Part B step therapy criteria re not met.

Medicare covers Part B medications when they are reasonable and necessary but allows health plans to implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain Part B medications. 

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 medication. Our physician reviewer found the provided records do not clearly show that you had tried and failed Retacrit. The provided records do not clearly support that the use of Retacrit or other treatment methods would likely be less effective and/or likely have more adverse effects than the requested Procrit. Retacrit and Procrit are clinically the same medication and have the same risks and benefits according to current literature. 

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 medication have not been met. Therefore, we decided that the Plan does not have to pre-approve Procrit (CPT code J0885, 96372, 85018).
Appeal type: Hospice
Decision: Unfavorable

 
We decided that the Plan does not have to pay for laboratory services provided on February 23, 2021. 
 
You asked the Plan to pay for laboratory 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 
members 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. Original Medicare is responsible for payment for services until the first day of the month after the 
hospice election has been revoked or terminated. The enrollee ended Medicare Hospice benefits on February 16, 2021. The services in question were provided 
before the end of that month. Therefore, we decided that the Plan does not have to pay for laboratory services 
provided on February 23, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an out-of-network primary care visit 
provided on December 7, 2021. 
 
You asked the Plan to waive the copayment for an out-of-network primary care visit. You say that you should 
not have a copayment for this visit. The Plan denied your request. The Plan says the copayment was applied 
correctly. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $40 
copayment for Physician/Practitioner services, including doctors office visits.  
 You have been asked to pay a $40 copayment for an out-of-network primary care visit. an out-of-network 
primary care visit falls within the Physician/Practitioner Services, Including Doctors 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 an out-of-network primary care visit provided 
on December 7, 2021.