Persius/hicric huggingface dataset:
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a transcutaneous electrical nerve stimulation (TENS) unit 
provided to the enrollee on November 7, 2021. 
 
You asked the Plan to pay for the services. You say that this was prescribed by a licensed physician to include 
State of Medical Necessity & Durable Medical Equipment (DME) certification, and helping with symptoms. 
The Plan denied your request. The Plan says a qualifying face-to-face encounter is required each time a new 
order/prescription for one of the specified items on the Required List is ordered. 
 
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 pay for the services. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found that the order form and the physician note do not met the requirements. There is no documentation of a 
physical exam in the six months prior to this date of service. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the services have not been met. Therefore, we decided that the Plan does not 
have to pay for a transcutaneous electrical nerve stimulation (TENS) unit provided to the enrollee on 
November 7, 2021.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for home health services provided on February 8, 2022, to 
March 1, 2022, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for home 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 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 home health services provided on February 8, 
2022, to March 1, 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 provided on July 30, 2021 billed with 
codes 81230, 81240, 81241, 81249, 81291, 81335, & 81408. 
 
You asked the Plan to pay for the genetic testing billed. You say that the services were medically necessary. 
The Plan denied your request. The Plan says the claim cannot be paid as billed. 
 
The Plan must follow Medicare rules. The rules say that if one laboratory procedure evaluates multiple genes 
using a next generation sequencing (NGS) procedure, the laboratory shall report only one unit of service of one 
genomic sequencing procedure, molecular multianalyte assay, multianalyte assay with algorithmic analysis, or 
proprietary laboratory analysis code. 
 
We looked at the file and Medicare rules. This was an NGS panel that was not billed with a single panel code 
as required. Based on this information, we decided that Medicare rules for coverage of the genetic testing billed have not been met. Therefore, we decided that the Plan does not have to pay for the genetic testing provided on 
July 30, 2021 billed with codes 81230, 81240, 81241, 81249, 81291, 81335, & 81408.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pay for medication assisted treatment provided on January 26, 2021, 
to September 27, 2021, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for medication assisted treatment. You say that you would like to request 
reconsideration of the denied claim. The Plan denied your request. The Plan says the provider is out-of-network 
and authorization is required prior to an out-of-network visit. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 The requested provider in this case is not a network provider with the Plan. The Plan had network providers 
available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the 
item/service at issue. We found no exception that would require the Plan to pay for these items/services. 
Therefore, we decided that the Plan does not have to pay for medication assisted treatment provided on January 
26, 2021, to September 27, 2021, by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve genicular nerve blocks. 
 
You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied 
your request. The Plan says the services are 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 these services. Our reviewer says that 
the services are not medically necessary. Our physician reviewer found the records show that you have pain in 
both knees. The requested genicular nerve block is considered experimental/investigational in nature. The 
services are therefore not reasonable or medically 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 these services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve genicular nerve blocks.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for psychotherapy services (90832) provided March 2, 2022 to 
March 11, 2022. 
 
You asked the Plan to pay for the psychotherapy services. You say that the service was medically necessary. 
The Plan denied your request. The Plan says the documentation does not support the billed service. 
 
The Plan must follow Medicare rules. Medicare rules say that for psychotherapy services to be covered, there 
must be an individualized treatment plan that states the type, amount, frequency, and duration of the services to 
be furnished and indicates the diagnoses and anticipated goals. 
 
We looked at the file and Medicare rules. The records did not include an individualized treatment plan. Based 
on this information, we decided that Medicare rules for coverage of the psychotherapy services have not been 
met. Therefore, we decided that the Plan does not have to pay for psychotherapy services (90832) provided 
March 2, 2022 to March 11, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the genetic testing provided on September 30, 2021, billed 
with codes 81238, 81226, 81335, 81230, 81241, 81291, and 81240. 
 
You asked the Plan to pay for the genetic testing billed. 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 if one laboratory procedure evaluates multiple genes 
using a next generation sequencing (NGS) procedure, the laboratory shall report only one unit of service of one 
genomic sequencing procedure, molecular multianalyte assay, multianalyte assay with algorithmic analysis, or 
proprietary laboratory analysis code. 
 
We looked at the file and Medicare rules. This was an NGS panel that was not billed with a single panel code 
as required. Based on this information, we decided that Medicare rules for coverage of the genetic testing billed 
have not been met. Therefore, we decided that the Plan does not have to pay for the genetic testing provided on 
September 30, 2021, billed with codes 81238, 81226, 81335, 81230, 81241, 81291, and 81240.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve incontinence supplies (T4522). 
 
You asked the Plan to pre-approve incontinence supplies. You say that these items are medically necessary. 
The Plan denied your request. The Plan says this is not a covered item. 
 
The Plan covers all items that Medicare covers. Medicare rules state that incontinence supplies are not covered 
because they are hygienic items that are non-reusable.  
 
While incontinence supplies 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 incontinence supplies (T4522).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services (80050, 84480, 85652) provided January 10, 
2022. 
 You asked the Plan to pay for the lab services. You say that the services were medically necessary. The Plan 
denied your request. The Plan says the claim cannot be paid. 
 
The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few 
tests listed in the Medicare rules section, are not covered. 
 
The lab services were requested solely for screening purposes. Medicare does not cover this test solely for 
screening purposes. Code 80050 is excluded from Medicare payment. Therefore, we decided that the Plan does 
not have to pay for lab services (80050, 84480, 85652) provided January 10, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for subsequent nursing facility care provided on February 16, 
2022, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for subsequent nursing facility care. You say that you would like to request 
reconsideration of the denied claim. The Plan denied your request. The Plan says the provider is out-of-network 
and authorization is required prior to an out-of-network visit. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 The requested provider in this case is not a network provider with the Plan. The Plan had network providers 
available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the 
item/service at issue. We found no exception that would require the Plan to pay for these items/services. 
Therefore, we decided that the Plan does not have to pay for subsequent nursing facility care provided on 
February 16, 2022, by an out-of-network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for laboratory services provided to the enrollee on November 5, 
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 the denied codes remain not supported. 
 
The Plan must follow Medicare rules. Medicare rules say that the provider, supplier, or beneficiary, as 
appropriate, must furnish to the intermediary or carrier sufficient information to determine whether payment is 
due and the amount of payment. 
 
We looked at the file and Medicare rules. Based on this information, we decided that there is insufficient 
information in the record to determine if Medicare rules for coverage of laboratory services provided to the 
enrollee on November 5, 2021. have been met. The laboratory did not send in the laboratory results for these services. The services cannot be verified.. Therefore, we decided that the Plan does not have to pay for 
laboratory services provided to the enrollee on November 5, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for laboratory services provided on February 10, 2022 by an out-
of-network (OON) provider. 
 
You asked the Plan to pay for laboratory services. You say that you would like to request reconsideration of the 
denied claim. The Plan denied your request. The Plan says the provider is out-of-network, and 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 laboratory services provided on February 10, 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 outpatient visit provided on January 19, 2022, by an out-
of-network (OON) provider. 
 
You asked the Plan to pay for the outpatient visit. The Plan denied your request. The Plan says the services 
were provided out-of-network and 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 the outpatient visit provided on January 19, 2022, 
by an out-of-network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services (82310, 82728, 83540, 83550, 83970, 84100) 
provided November 3, 2021. 
 
You asked the Plan to pay for the lab services. You say that the services were medically necessary. The Plan 
denied your request. The Plan says the lab services are not separately payable. 
 
The Plan must follow Medicare rules. Medicare rules state that routine ESRD lab services are not separately 
payable. Labs should bill the facility directly for lab 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 
lab services (82310, 82728, 83540, 83550, 83970, 84100) provided November 3, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the chiropractic manipulative treatment (98941) provided on 
April 27, 2022, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for the chiropractic treatment. You say that these services were medically necessary. 
The Plan denied your request. The Plan says the services were provided out-of-network and 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 the chiropractic manipulative treatment (98941) 
provided on April 27, 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 arthrocentesis, aspiration and/or injection provided on 
December 2, 2021. 
 
You asked the Plan to pay for the arthrocentesis, aspiration and/or injection. The Plan denied your request. The 
Plan says 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 Plan says that the Plan has also determined that these services 
are not urgent or emergent, nor were they 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 did not pre-approve the 
services at issue. We found no exception that would require the Plan to pay for these services. Therefore, we 
decided that the Plan does not have to pay for an arthrocentesis, aspiration and/or injection provided on 
December 2, 2021.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 93042 billed for date of service December 
10, 2021. 
 
You asked the Plan to pay for procedure code 93042. You say that this service was medically necessary. The 
Plan denied your request. The Plan says payment for code 93042 is bundled into payment for code G0168.  
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 93042 
is has a bundled relationship with code G0168. 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 93042 billed for date of service December 10, 
2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the acute inpatient hospital care provided from June 20, 
2021, through June 24, 2021. 
 
You asked the Plan to pay for these services. You say that you are requesting a reconsideration of the Plan's 
denial for payment. The Plan denied your request. The Plan says the services provided were not medically 
necessary. 
 
The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor 
expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases, 
consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or 
more.   
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 these services. Our reviewer says that the 
documentation does not support that the criteria for inpatient payment are met in this case. Our physician 
reviewer found that the enrollee presented to the emergency department (ED) due to left hip pain that was 
ongoing for two weeks. She was able to ambulate without difficulties or a walker. The x-ray taken showed 
osteoarthritis. Her medication was thrown out and she could not remember what medication she was supposed 
to be taking. She was admitted for social reasons and possible placement. The review has determined that the 
record did not show that at the time of the inpatient admission, the admitting physician reasonably expected 
that the enrollees necessary hospital care (including earlier ED and/or observation care) would span two 
midnights. 
 
We looked at this physician's review, the file, and Medicare rules. 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 acute inpatient hospital care provided from June 20, 2021, through June 24, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the genetic testing provided on March 28, 2021 billed with 
codes 81295, 81298, 81317, 81402, 81162, 81191 and 81309:. 
 
You asked the Plan to pay for the genetic testing billed. You say that the services were medically necessary. 
The Plan denied your request. The Plan says the claim cannot be paid as billed. 
 
The Plan must follow Medicare rules. The rules say that if one laboratory procedure evaluates multiple genes 
using a next generation sequencing (NGS) procedure, the laboratory shall report only one unit of service of one 
genomic sequencing procedure, molecular multianalyte assay, multianalyte assay with algorithmic analysis, or 
proprietary laboratory analysis code. 
 
We looked at the file and Medicare rules. This was an NGS panel that was not billed with a single panel code 
as required. Based on this information, we decided that Medicare rules for coverage of the genetic testing billed have not been met. Therefore, we decided that the Plan does not have to pay for the genetic testing provided on 
March 28, 2021 billed with codes 81295, 81298, 81317, 81402, 81162, 81191 and 81309:.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for eyeglasses provided on January 19, 2022. 
 
You asked the Plan to pay for the eyeglasses. You say that you received your prescription from an in-network 
optometrist, however their office did not offer eyeglasses and due to relying on others for transportation, you 
chose a local place to buy the eyeglasses. The Plan denied your request. The Plan says there is no coverage for 
vision services with an out-of-network provider. 
 
Medicare generally does not cover routine eyewear services. However, the Plan offers a routine 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 the Plans 
vision 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 
January 19, 2022.