Persius/hicric huggingface dataset:
Appeal type: Hospice
Decision: Unfavorable

 
We decided that the Plan does not have to pay for skilled nursing visit in your home (G0299) provided on 
February 20, 2022. 
 
You asked the Plan to pay for the home health care. You say that you were given this enrollee as a referral with 
authorization to perform specific services. You also say that the services should be paid. The Plan denied your 
request. The Plan says the enrollees claim would be covered under Original Medicare as it is responsible for 
coverage of Part B benefits starting on the date of election until the last day of the month in which hospice is 
revoked. The Plan also says it is the providers responsibility to verify the enrollees coverage before rendering 
services and to know proper billing procedures for a Medicare Advantage member on hospice. 
 
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Medicare is responsible for payment for services until the first day of the month after the hospice election has been revoked or terminated.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 14, 2022. The services in question were provided 
before the end of that month. Therefore, we decided that the Plan does not have to pay for skilled nursing visit 
in your home (G0299) provided on February 20, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to reimburse for OTC COVID-19 test purchased on April 28, 2022. 
 
You asked the Plan to reimburse for OTC COVID-19 test. You say that you want to be reimbursed for the 
purchase of an OTC COVID-19 test. The Plan denied your request. The Plan says they are not responsible for 
reimbursing OTC COVID-19 test. 
 
The Plan must follow Medicare rules. Medicare rules say that starting April 4, 2022, over-the-counter (OTC) 
COVID-19 tests are covered by Original Medicare, so Medicare Advantage plans are not responsible for 
reimbursement of these test. 
 
We looked at the file and Medicare rules. Based on this information, we decided that since this OTC COVID-
19 test was purchased after April 3, 2022, the Plan is not responsible for reimbursement of it. Please contact the 
Plan for more information about how to request reimbursement from Original Medicare. Therefore, we decided 
that the Plan does not have to reimburse for OTC COVID-19 test purchased on April 28, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code S9328 billed for date of service May 21, 
2022, to June 17, 2022. 
 
You asked the Plan to pay for procedure code S9328. You say that this is a service-only code and should be 
paid. 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 May 21, 2022, to June 17, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit provided on January 11, 2022, by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for an office visit. You say that the services provided were medically necessary. 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 January 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 wound care services provided on September 27, 2021, by an 
out-of-network (OON) provider. 
 
You asked the Plan to pay for wound care 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 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 wound care services provided on September 27, 
2021, 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 (81404, 81405, 81406, 81479) provided on 
November 24, 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 coverage criteria has not been met. 
 
The Plan must follow Medicare rules. Medicare rules say that only the following codes should be billed for 
Cardiovascular Disease Screening: code 80061 (Lipid panel) which includes CPT codes: 82465 (Cholesterol, 
serum or whole blood, total), 83718 (Lipoprotein, direct measurement; high density cholesterol) and/ or 84478 
(Triglycerides). 
 
 
 We looked at the file and Medicare rules. The codes billed are not eligible for coverage for cardiovascular 
screening. Based on this information, we decided that Medicare rules for coverage of the lab services have not 
been met. Therefore, we decided that the Plan does not have to pay for lab services (81404, 81405, 81406, 
81479) provided on November 24, 2021.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ambulance response and treatment, no transport, (A0998) 
and supplies (A0999) provided on March 19, 2022. 
 
You asked the Plan to pay for the ambulance services. You say that the enrollee fell and hit their hip. You say 
that the enrollee did not want to go to the hospital. You say that you needed help getting the enrollee up. You 
also say that they needed to be checked out. The Plan denied your request. The Plan says since there was no 
transport provided, there is no payable service. 
 
The Plan must follow Medicare rules. The rules say that Medicare does not pay for ambulance services when 
there is no transport.  
 
The ambulance company did not provide transport services on March 19, 2022. The ambulance benefit is a 
transportation benefit. When there is no transport, neither Medicare nor the Plan pays for the services provided. 
Therefore, we decided that the Plan does not have to pay for the ambulance response and treatment, no 
transport, (A0998) and supplies (A0999) provided on March 19, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. You say that are appealing the denied preservice authorization. 
 The Plan denied your request. The Plan says the IRF care is not medically necessary, and your needs can be 
met at a lower level of care such as a skilled nursing facility (SNF). 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 
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 IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found you were admitted for congestive heart failure and pleural effusion and was discharged home on September 23, 2022, with ongoing weakness. The record shows your medical problems 
are stable, and there are no complex nursing or rehabilitation needs. You do not require treatment by multiple 
therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation therapy 
program. While the medical record supports a need for physical and/or occupational therapy, there is no 
documented need for intensive rehabilitation services. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit provided on April 30, 2022 by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for the office 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 office visit provided on April 30, 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 domiciliary or rest home visit provided on April 22, 2022, 
by an OON provider. 
 
You asked the Plan to pay for a domiciliary or rest home visit. You say that the provider saw the enrollee in a 
facility and the facility should have obtained the prior authorization. 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 a domiciliary or rest home visit provided on April 
22, 2022, by an OON provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit provided on June 14, 2022, by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for an office visit. 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 an office visit provided on June 14, 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 May 5, 2022, by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for an office visit. You say that all of your providers are out-of-network due to no 
contract. The Plan denied your request. The Plan says services from non-participating providers are not covered 
under your plan unless they are authorized by the Plan before the services are provided. 
 
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 May 5, 2022, by an 
out-of-network (OON) provider.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pay for skilled nursing facility (SNF) services provided to the 
enrollee from February 2, 2021, to March 9, 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 provider has reported skilled services with the incorrect PDPM Health Insurance Prospective 
Payment System (HIPPS) Score. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
 
We asked our coder to carefully review the case file and apply the relevant Medicare rules to determine if the 
Plan was correct in denying the request to pay for the services. Our reviewer says that the services at issue in 
this case were not supported by the medical records. Our reviewer found that an order for ceftriaxone, 2 grams 
IV is noted for the dates 02/11/2021 - 03/09/2021. The PICC line was to be discontinued on 3/9/21 after the last 
dose of IV antibiotic. The case file does not contain documentation of administration of IV ceftriaxone during 
the time period in question. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the services have not been met. Therefore, we decided that the Plan does not 
have to pay for skilled nursing facility (SNF) services provided to the enrollee from February 2, 2021, to March 
9, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory and pharmacy services provided on February 
22, 2022, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for the laboratory and pharmacy services. You say that it was medically necessary to 
treat the enrollee and you would like the claim reprocessed for payment. 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. 
 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 laboratory and pharmacy services provided on 
February 22, 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 injection services, therapeutic procedure, and nervous system 
procedure (J3490, 96372, 97139, 64999) provided on March 28, 2022 to March 30, 2022 by an out-of-network 
(OON) provider. 
 
You asked the Plan to pay for the injection services, therapeutic procedures, and nervous system procedure. 
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 injection services, therapeutic procedure, and 
nervous system procedure (J3490, 96372, 97139, 64999) provided on March 28, 2022 to March 30, 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 office visit services (G8427, 99214, G8419, G8942) 
provided on September 23, 2021 by an out-of-network (OON) provider. 
 
You asked the Plan to pay for the office visit services. 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 office visit services (G8427, 99214, G8419, 
G8942) provided on September 23, 2021 by an out-of-network (OON) provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. You say that the services are necessary. The Plan denied your 
request. The Plan says based on the documentation provided, coverage criteria has not been met. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 
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 IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found clinical documentation shows that you have functional impairments and initial 
injuries however, there is no documentation to support the need for close medical monitoring on an inpatient basis during rehabilitation. Additionally, there is no IRF compliant diagnosis or complex functional issues 
requiring a multi-disciplinary team approach or intense therapy. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 92526 billed for date of service December 
30, 2019. 
 
You asked the Plan to pay for procedure code 92526. You say that this should be paid for. The Plan denied 
your request. The Plan says the number of units billed exceeds the maximum allowed. 
 The Plan must follow Medicare rules. Medicare rules say that claims submitted where the unit of service 
exceeds the MUE value cannot be paid when the MAI value is 2.  
 
In this case, the MUE for CPT code 92526 is 1. The MAI value for this code is 2. You billed 3 units of this 
code, exceeding the MUE. Based on this information, we decided that Medicare rules for coverage of 
procedure code 92526 have not been met. Therefore, we decided that the Plan does not have to pay for 
procedure code 92526 billed for date of service December 30, 2019.