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

 
We decided that the Plan does not have to pay for a domiciliary or rest home visit provided on November 11, 
2021, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for a domiciliary or rest home visit. You say that the provider has no prior 
knowledge of which patients he will be required to see. You also say that it is not possible to request 
authorization before services are rendered. The Plan denied your request. The Plan says this provider is out-of-
network with the Plan. The Plan also said that authorization was not obtained prior to the services being 
rendered. 
  
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 domiciliary or rest home visit provided on 
November 11, 2021, by an out-of-network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for PrismRA testing (81599) provided on April 5, 2022. 
 
You asked the Plan to pay for PrismRA testing. You say that these services were necessary and were performed 
by a Clinical Laboratory Improvement Amendments (CLIA)-certified lab. The Plan denied your request. The 
Plan says this test is not approved by the FDA and therefore is not covered by Medicare. 
 
The Plan must follow Medicare rules. Medicare rules say that molecular diagnostic laboratory tests are subject 
to the MolDX application, assessment, and approval process. Once this is complete, the test is assigned a 
reimbursement rate and a unique test identifier. 
 
 
 
 
 
 
 We looked at the file and Medicare rules. This test is listed in the DEX database as non-covered. This 
determination was made and is specific to the test at issue. Based on this information, we decided that 
Medicare rules for coverage of PrismRA testing have not been met. Therefore, we decided that the Plan does 
not have to pay for PrismRA testing (81599) provided on April 5, 2022.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for transportation services provided on March 29, 2022, by an 
out-of-network (OON) provider. 
 
You asked the Plan to pay for transportation services. You say that you are appealing the decision denying the 
transport reimbursement. The Plan denied your request. The Plan says there was no primary care provider 
(PCP) referral and no preauthorization. 
 
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 transportation services provided on March 29, 
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 March 18, 2022, by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for the office visit. You say that it was medically necessary to treat the enrollee and 
you would like the denial of the claim waived. The Plan denied your request. The Plan says the rendering 
provider is an OON provider and there was no referral from an in-network provider or an approved 
authorization. Also, the service rendered was not urgent or emergent. 
 Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The requested provider in this case is not a network provider with the Plan. The Plan had network providers 
available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the 
item/service at issue. We found no exception that would require the Plan to pay for these items/services. 
Therefore, we decided that the Plan does not have to pay for an office visit provided on March 18, 2022, by an 
out-of-network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 81161 billed for date of service October 14, 
2021. 
 
You asked the Plan to pay for procedure code 81161. You say that this service was medically necessary and 
should be paid. The Plan denied your request. The Plan says payment for code 81161 is bundled into payment 
for code 81413. 
 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 81161 
is a column II code to column I code 81413. 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 81161 billed for date of service October 14, 
2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an outpatient hospital visit provided on April 8, 2022 by an 
out-of-network (OON) provider. 
 
You asked the Plan to pay for the outpatient hospital visit. You say that the services should be covered as you 
disagree with the denial. 
 The Plan denied your request. The Plan says the services denied correctly as they were non-emergent and prior 
authorization was not obtained. 
 
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 visit provided on April 8, 
2022 by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the services rendered on March 14, 2022. 
 
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 when billed by a chiropractor. 
 
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. The file shows that the 
chiropractor submitted a claim for procedure codes 77002 (needle localization by x-ray) and J7320 (Genvisc 
injection). Therefore, we decided that the Plan does not have to pay for the services rendered on March 14, 
2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a telephone evaluation provided on May 11, 2022, by an out-
of-network (OON) provider. 
 
You asked the Plan to pay for a telephone evaluation. You say that most of your employees are sick and it was 
not possible for you to get the authorization before the services were rendered. 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 a telephone evaluation provided on May 11, 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 rest home visit (99334) provided on December 23, 2021, 
by an out-of-network (OON) provider. 
 
You asked the Plan to pay for a rest home visit. You say that the providers rely on facility staff to verify 
eligibility and to obtain authorization from the enrollee's insurance. The Plan denied your request. The Plan 
says the claim was denied appropriately. Authorization was not obtained prior to the services being rendered, 
and there is no evidence indicating that the services were urgent or emergent. Furthermore, the Plan says the 
services were not Plan Directed Care. 
 
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 rest home visit (99334) provided on December 
23, 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 a domiciliary or rest home visit provided on December 16, 
2021, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for a domiciliary or rest home visit. You say that the provider has no prior 
knowledge of which patients he will be required to see. You also say that it is not possible to request 
authorization before services are rendered. The Plan denied your request. The Plan says this provider is out-of-
network with the Plan. The Plan also said that authorization was not obtained prior to the services being 
rendered. 
 
 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 domiciliary or rest home visit provided on 
December 16, 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 rest home visit and wound debridement (99334 11721) 
provided on April 13, 2022 by an out-of-network (OON) provider. 
 
You asked the Plan to pay for the rest home visit and wound debridement. You say that the services should be 
covered as you disagree with the denial. The Plan denied your request. The Plan says the services denied 
correctly as they were non-emergent and prior authorization was not obtained. 
 
  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 rest home visit and wound debridement (99334 
11721) provided on April 13, 2022 by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the radiology services provided on April 20, 2022, by an out-
of-network (OON) provider. 
 
You asked the Plan to pay for the radiology services. You say that the services provided to the enrollee was 
medically necessary. The Plan denied your request. The Plan says the rendering provider is an OON provider 
and there was no referral from an in-network provider or an approved authorization. Also, the service rendered 
was not urgent or emergent. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
  The requested provider in this case is not a network provider with the Plan. The Plan had network providers 
available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the 
item/service at issue. We found no exception that would require the Plan to pay for these items/services. 
Therefore, we decided that the Plan does not have to pay for the radiology services provided on April 20, 2022, 
by an out-of-network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the comprehensive oral evaluation (code D0150) you 
received on April 7, 2022. 
 
You asked the Plan to pay for the dental services. You say that you switched to a new dentist closer to your 
home and the new dentist needed to do a full exam. The Plan denied your request. The Plan says your benefit 
for the requested item or service has already been exhausted. 
 
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. This limitation applies 
regardless of the reason for the service. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, certain limitations apply. The record 
shows your benefit for the requested item or service was exhausted on date of service March 2, 2021. 
Therefore, we decided that the Plan does not have to pay for the comprehensive oral evaluation (code D0150) 
you received on April 7, 2022.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayments for . 
 
You asked the Plan to waive the copayments for the colonoscopy and laboratory test. You say that you are 
appealing this cost-sharing. The Plan denied your request. The Plan says you have been charged the correct 
cost sharing amount. 
 
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 $275 copayment for an ambulatory surgical center visit and a $5 copayment for lab services.  
 
You have been asked to pay a total of $280 for the colonoscopy and laboratory test ($275 + $5 = $280). The 
colonoscopy falls within the Outpatient Surgery, Including Services Provided at Hospital Outpatient Facilities 
and Ambulatory Surgical Centers benefit category. The laboratory test falls within the Outpatient Diagnostic 
Tests and Therapeutic Services and Supplies benefit category. The record shows a lesion was removed during 
your colonoscopy. Therefore, the colonoscopy is considered diagnostic, and the outpatient surgery copayment 
applies. 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 copayments for the colonoscopy and laboratory test provided 
on March 1, 2022. .
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a comprehensive periodontal evaluation (D0180) provided 
on April 26, 2022. 
 
You asked the Plan to pay for an evaluation. You say that you disagree with the denial of dental services. The 
Plan denied your request. The Plan says a comprehensive periodontal evaluation (D0180) is not covered by 
your dental benefits. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for a 
comprehensive periodontal evaluation (D0180) provided on April 26, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 70450-26 billed for date of service October 
15, 2021. 
 
You asked the Plan to pay for procedure code 70450-26. You say that you have provided medical records to 
support payment. The Plan denied your request. The Plan says payment for code 70450-26 is bundled into 
payment for code 70496-26. 
 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 
70450-26 is a column II code to column I code 70496-26. 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 70450-26 billed for date of service 
October 15, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a power mobility scooter (K0899) provided on February 10, 
2022, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for a power mobility scooter. You say that you spoke to a Plan representative on 
March 6, 2022, and you were told you only need a receipt to get reimbursed. You say you were not advised that 
you need to go to an in-network provider, or that a prior authorization is required. The Plan denied your 
request. The Plan says the claim was processed in accordance with your contract. 
 
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 item at issue in this appeal. The Plan did not pre-approve the item at 
issue. We found no exception that would require the Plan to pay for this item. Therefore, we decided that the 
Plan does not have to pay for a power mobility scooter (K0899) provided on February 10, 2022, by an out-of-
network (OON) provider.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for skilled nursing facility (SNF) care on 
January 07, 2022, to January 31, 2022. 
 
You asked the Plan to waive the copayment for skilled nursing facility (SNF) care. You say that you want to 
appeal the amount being charged. The Plan denied your request. The Plan says the cost sharing the enrollee is 
being charged 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). The enrollees contract with the Plan clearly says that enrollees 
must pay a $184 copayment per day for days 21 through 40 for skilled nursing facility (SNF) care. You are 
covered for up to 100 days per benefit period. Unlike traditional Medicare, you do not need to be in the in the 
hospital for 3 days prior to going to an SNF. The provider billed 25 days. Days 1-20 have no cost share. Days 
21-25 is 5 days. 5 x $184.00 = $920.0. Therefore, results in the total cost sharing amount of $920. 
 
 The enrollee has been asked to pay a $184 copayment per day for skilled nursing facility (SNF) care. Skilled 
nursing facility (SNF) care falls within the skilled nursing facility (SNF) care benefit category. This means that 
the enrollee has been asked to pay the correct amount based on the contract with the Plan. This cost sharing is a 
contractual obligation the enrollee agreed to pay upon enrolling in the Plan. Therefore, we decided that the Plan 
does not have to waive the copayment for skilled nursing facility (SNF) care on January 07, 2022, to January 
31, 2022.
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 March 28, 
2022. 
 
You asked the Plan to pay for procedure code 99100. You say that you disagree with the denial. 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 March 28, 2022.