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

 
We decided that the Plan does not have to pre-approve an office visit to be provided by the requested out-of-
network provider. 
 
You asked the Plan to pre-approve an office visit to be provided by the requested out-of-network provider. The 
Plan denied your request. The Plan says there are available in-network providers in your area that can provide 
this service. 
 
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 pre-approve care from out-of-network providers only in cases involving 
emergencies, out of area urgent care and care that cannot be provided by network providers. 
 
The requested provider in this case is not a network provider with the Plan. The Plan has network providers 
available who can provide the services at issue in this appeal. We found no exception that would require the 
Plan to pre-approve these services. Therefore, we decided that the Plan does not have to pre-approve an office 
visit to be provided by the requested out-of-network provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a limited oral evaluation (D0140) and a periapical x-ray 
(D0220) provided on March 24, 2022. 
 
You asked the Plan to pay for the dental services. You say that you disagree with the denial of dental services. 
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 limited oral evaluation (D0140) and a periapical x-ray (D0220) provided on March 24, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for subsequent nursing facility care provided on March 9, 2022, 
by an out-of-network (OON) provider. 
 
You asked the Plan to pay for subsequent nursing facility care. You say that the rendering physician is a 
hospitalist physician with the group and depends upon the hospital staff to verify eligibility and to obtain the 
proper authorization from the member's insurance company. The Plan denied your request. The Plan says 
services from non-participating providers are not covered unless preauthorized. 
 
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 subsequent nursing facility care provided on 
March 9, 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 October 19, 2021, by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for an office visit. You say that you would like to appeal the denial of the 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 office visit provided on October 19, 2021, by 
an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for home visit services provided on March 29, 2022, by an out-
of-network (OON) provider. 
 
You asked the Plan to pay for home visit services. You say that you would like to request reconsideration for 
payment. The Plan denied your request. The Plan says the provider is out-of-network, and it was determined 
these services can be received in-network. 
 
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 home visit services provided on March 29, 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 genetic testing (Guardant360 panel) provided on April 5, 
2022, billed with codes 81120, 81121, 81173, 81201, 81210, 81235, 81270, 81272, 81275, 81276, 81293, 
81299, 81301, 81308, 81309, 81310, 81311, 81314, 81318, 81321, 81400, 81401 x2, 81402, 81403 x2, 81404 
x2, 81405 x2 and 81406 x2. 
 
You asked the Plan to pay for the genetic testing billed. You say that this testing was medically necessary The 
Plan denied your request. The Plan says this claim was not billed in accordance with Medicare rules. The 
Guardant360 panel has an established CPT code of 0242U. Instead, this claim was submitted with stacking 
gene codes. 
 
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 
(Guardant360 panel) provided on April 5, 2022, billed with codes 81120, 81121, 81173, 81201, 81210, 81235, 
81270, 81272, 81275, 81276, 81293, 81299, 81301, 81308, 81309, 81310, 81311, 81314, 81318, 81321, 81400, 
81401 x2, 81402, 81403 x2, 81404 x2, 81405 x2 and 81406 x2.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services related to end-stage renal disease 
(ESRD) provided on November 16, 2021. 
 
You asked the Plan to pay for the ESRD-related laboratory services. You say that your organization does not 
have a contract with the dialysis facility for payment of these lab services. The Plan denied your request. The 
Plan says Medicare does not separately pay for ESRD-related laboratory testing. 
 
The Plan must follow Medicare rules. Medicare rules state that routine ESRD laboratory services are not 
separately payable. Laboratories should bill the facility directly for laboratory services as they are considered 
part of the composite rate. No other payment for these services is allowed. Therefore, we decided that the Plan 
does not have to pay for the laboratory services related to end-stage renal disease (ESRD) provided on 
November 16, 2021.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pay for speech therapy (ST) provided on July 10, 2020. 
 
You asked the Plan to pay for the ST. You say that the claim could not be submitted within the required time 
frame because the enrollee's updated information was not received in time. The Plan denied your request. The 
Plan says you failed to submit the claim within the timely filing limits. 
 
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 ST was not filed until April 28, 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 speech therapy (ST) provided on July 10, 2020.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for outpatient mental health services provided on January 11, 
2022, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for outpatient mental health services. You say that you would like to request 
reconsideration for payment. The Plan denied your request. The Plan says the provider is out-of-network, and it 
was determined these services can be received in-network. 
 
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 outpatient mental health services provided on 
January 11, 2022, by an out-of-network (OON) provider.
Appeal type: Lab
Decision: Favorable

 
We decided that the Plan has to pay for the laboratory services rendered on July 28, 2021. 
 
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says that the services are not covered. 
 
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and 
diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or 
payment. 
 
The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their 
decision to deny your request. the Plan references Local Coverage Articles (LCA) A55183 and A55113 in their 
determination; which are not binding for the services at issue and is superseded by National Coverage 
Determination (NCD) 90.2, which allows for coverage of this testing. Therefore, we decided that the Plan has 
to pay for the laboratory services rendered on July 28, 2021.  
 
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again 
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake 
and/or send us the new information. This does not happen often. If we decide to open the case again, we will 
send you a letter.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a neuropsychological testing evaluation. 
 
You asked the Plan to pre-approve a neuropsychological testing evaluation. You say that a neuropsychological 
testing evaluation is medically necessary. The Plan denied your request. The Plan says a neuropsychological 
testing evaluation does not meet the Medicare coverage criteria. 
 
The Plan follows Medicare rules.  
 
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 neuropsychological testing 
evaluation. Our reviewer says that a neuropsychological testing evaluation is not medically necessary. Our 
physician reviewer found that based on review the records provided, this enrollee has had difficulty with 
memory loss, inability to hold a conversation and perform household chores as basically being a workup for 
Dementia. The enrollee has no previous history of mental health disorder that has only shown memory 
difficulties worsening since the last visit. Utilizing the criteria from LCD L33632 that this testing is intended to 
diagnose and characterize the neurocognitive effects of medical disorders that impinge directly on or indirectly 
on the brain including detection of neurologic disease based on quantitative assessment of neurocognitive 
abilities, differential diagnosis between psychogenic and neurogenic syndromes, delineation of neurocognitive 
effects of central nervous system disorders, neurocognitive monitoring of recovery or progression of central 
nervous system disorders or assessment of neurocognitive function for the formulation of rehabilitation and/or 
management strategies among individuals with neuropsychiatric disorders. This enrollee does not meet the 
criteria as the enrollee is not showing severity of symptoms that would warrant this type of diagnostic treatment 
and is therefore not appear medically necessary or reasonable.  
 
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 neuropsychological testing evaluation have not been met. Therefore, we 
decided that the Plan does not have to pre-approve a neuropsychological testing evaluation.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve physician's services to be provided by the requested  
out-of-network provider. 
 
You asked the Plan to pre-approve physician's services to be provided by the requested out-of-network 
provider. You say that you have been trying to get a pain specialist from the medical group but cannot get hold 
of the in-network specialist so you went out-of-network. The Plan denied your request. The Plan says the 
provider is out-of-network. The requested office visit for the back pain is not emergent and can be provided by 
an in-network provider. 
 
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 pre-approve care from out-of-network providers only in cases involving 
emergencies, out of area urgent care and care that cannot be provided by network providers. 
 
 
 
 
 The requested provider in this case is not a network provider with the Plan. The Plan has network providers 
available who can provide the services at issue in this appeal. We found no exception that would require the 
Plan to pre-approve these services. Therefore, we decided that the Plan does not have to pre-approve 
physician's services to be provided by the requested out-of-network provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a fluid circulating cold pad with pump. 
 
You asked the Plan to pre-approve these services. You say that you need the machine after knee replacement 
surgery. The Plan denied your request. The Plan says the services are not covered. 
 
The Plan must follow Medicare rules. The rules say that a fluid circulating cold pad with pump (E0218) will be 
denied as not reasonable and necessary.  
 
We looked at the file and Medicare rules. The requested item is denied by Medicare as not medically 
necessary. Therefore, we decided that the Plan does not have to pre-approve a fluid circulating cold pad with 
pump.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a shower chair and a grab bar. 
 
You asked the Plan to pre-approve a shower chair and a grab bar. You say that you are at risk of falling without 
these items. The Plan denied your request. The Plan says these items are not a covered benefit. 
 
The Plan must follow Medicare rules. Medicare rules say that shower chairs are not covered because they are 
not primarily medical in nature. Grab bars are not covered because they are considered self-help items that are 
not primarily medical in nature. 
 
While a shower chair and a grab bar may be appropriate in this case, neither the Plan nor Medicare offers 
coverage of these items. Therefore, we decided that the Plan does not have to pre-approve a shower chair and a 
grab bar.
Appeal type: SNF
Decision: Partially Favorable

 
We decided that the Plan has to waive the copayment for one day of the SNF stay. We decided that the Plan 
does not have to waive the copayment for seven days of the SNF stay.  
 
You asked the Plan to waive the copayment for your entire SNF stay. You say that you should not have a copay 
for this stay, you believe you are being billed incorrectly. The Plan says that you have been charged the correct 
cost sharing amount. 
 
We decided that the Plan has to waive the copayment for one day of the SNF stay.  
 
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 $184 
copayment per day for days 21-100 of skilled nursing facility (SNF) care. You previously received 12 days of 
SNF care in October and November 2021. This SNF stay lasted 15 days, which are days 13 to 27 of the SNF 
benefit period, resulting in a total of 27 days. 
 
The file shows that you have a medical indication for which Medicare will cover SNF services. Therefore, we 
decided that the Plan has to waive the copayment for one day of the SNF stay.  
 
We also decided that the Plan does not have to waive the copayment for seven days of the SNF. 
 
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 $184 
copayment per day for days 21-100 of skilled nursing facility (SNF) care. You previously received 12 days of 
SNF care in October and November 2021. This SNF stay lasted 15 days, which are days 13 to 27 of the SNF 
benefit period, resulting in a copayment amount of $1288. 
 
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again 
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake 
and/or send us the new information. This does not happen often. If we decide to open the case again, we will 
send you a letter.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the office visit rendered on December 21, 2021. 
 
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says the services are not covered. 
 
The Plan must follow Medicare rules. Medicare rules say that if more than one evaluation and management 
(face-to-face) service is provided on the same day to the same patient by the same physician or more than one 
physician in the same specialty in the same group, only one evaluation and management service may be 
reported. 
 
We looked at the file and Medicare rules. The file shows that the same physician reported two evaluation and 
management services for the billed date of service. Based on this information, we decided that Medicare rules 
for coverage of these services have not been met. Therefore, we decided that the Plan does not have to pay for 
the office visit rendered on December 21, 2021.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to pay for The emergency department services provided on January 15, 
2022. 
 
You asked the Plan to pay for the emergency department services. You say that you would like reconsideration 
because the services rendered were medically necessary. The Plan denied your request. The Plan says the 
facility does not meet criteria to provide services to Medicare members 
 
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. Additionally, CMS has indicated that current law does not recognize 
IFEDs as a certified Medicare provider. 
 
Review of the file and Medicare records indicates that this facility is an IFED and not affiliated with a hospital. Therefore, we decided that the Plan does not have to pay for The emergency department services provided on 
January 15, 2022.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the psychotherapy services (90837) provided on April 18, 
2022. 
 
You asked the Plan to pay for procedure code 90837. 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 must follow Medicare rules. Medicare rules say that the CP or LCSW must document, in the patient's 
medical record, the date the patient consented or declined consent to consultations, the date of consultation, or, 
if attempts to consult did not succeed, that date and manner of notification to the physician. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of procedure code 90837 have not been met. Specifically, the record does not include documentation 
of a consultation or an attempt to consult the enrollee's primary/attending physician as required by Medicare 
rules. Therefore, we decided that the Plan does not have to pay for the psychotherapy services (90837) 
provided on April 18, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for FoundationOne testing (0037U) provided on September 29, 
2021. 
 
You asked the Plan to pay for FoundationOne 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. Medicare rules say that to report a Molecular Diagnostic Test service, 
providers should enter the appropriate DEX Z-Code identifier adjacent to the Current Procedural Terminology 
(CPT) code in the comment/narrative field on the claim. 
 
We looked at the file and Medicare rules. A DEX Z-Code identifier was not reported on the claim for this 
Molecular Diagnostic Test service. Based on this information, we decided that Medicare rules for coverage of 
FoundationOne testing have not been met. Therefore, we decided that the Plan does not have to pay for 
FoundationOne testing (0037U) provided on September 29, 2021.