Persius/hicric huggingface dataset:
Appeal type: Practitioner Services
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 April 25, 2022. 
 
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 April 
25, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit (99205) provided on March 8, 2022, by an 
out-of-network (OON) provider. 
 
You asked the Plan to pay for an office visit. You say that the enrollee significantly benefited from the services 
provided and you request that the services be covered. The Plan denied your request. The Plan says the claim 
was processed correctly. The rendering provider in this case is not a participating 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 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 (99205) provided on March 8, 2022, 
by an out-of-network (OON) provider.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve specialist office visit to be provided by an out-of-
network (OON) provider. 
 
You asked the Plan to pre-approve specialist office visit. You say that you are willing to see an in-network 
senior surgeon for this consultation. The Plan denied your request. The Plan says the service 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 items/services at issue in this appeal. We found no exception that would require 
the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve 
specialist office visit to be provided by an out-of-network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve custom shoes (L3216, L3230) and inserts (L3002). 
 
You asked the Plan to pre-approve these items. You say that you are requesting a reconsideration of the Plan's 
denial. The Plan denied your request. The Plan says these items are not covered under the enrollees contractual 
policy or by Medicare for her condition. 
 
Medicare rules state that supportive devices for the feet (such as orthopedic footwear) are only covered for 
patients with diabetic foot disease or for patients who wear a leg brace. The Plan follows these same rules.   
 
Records show that the enrollee does not suffer from diabetic foot disease and does not wear a leg brace. 
Although custom shoes and inserts may be appropriate for her, neither Medicare nor the Plan provides 
coverage of these items for her condition. Additionally, with the exception of the situations described above, 
orthopedic footwear billed using codes L3002, L3216, and L3230 will be denied as non-covered. Therefore, we 
decided that the Plan does not have to pre-approve custom shoes (L3216, L3230) and inserts (L3002).
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Prolia. 
 
You asked the Plan to pre-approve Prolia. The Plan denied your request. The Plan says the enrollee has not met 
the step therapy criteria. 
 
Medicare covers Part B medications when they are reasonable and necessary but allows health plans to 
implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain 
Part B medications.  
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve Prolia. Our reviewer says that Prolia is 
not medically reasonable and necessary in this case. Our physician reviewer found that there is no indication 
that the enrollee has tried and failed the required drug(s) or that the enrollee has a history of osteoporosis-
related fracture. Based on the medical records provided and the Medicare-approved major drug compendia, 
there is no indication that the Plan's required drug(s) would likely be less effective and/or likely have adverse 
effects for the enrollee. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Prolia have not been met. Therefore, we decided that the Plan does not have to 
pre-approve Prolia.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acupuncture treatments. 
 
You asked the Plan to pre-approve these services. You say that you are requesting a reconsideration of the 
Plan's denial. The Plan denied your request. The Plan says you do not meet criteria for coverage of the 
requested services. 
 
The Plan must follow Medicare rules. The rules say that acupuncture services are not covered by Medicare. 
However, for services provided on or after January 21, 2020, Medicare offers limited coverage for acupuncture 
treatments for CLBP meeting certain requirements, up to 12 sessions per 90-day period, and no more than 20 
sessions per year.  
 
We looked at the file and Medicare rules. Based on this information, we decided that the rules for coverage of 
the acupuncture services have not been met.  Specifically, the records provided do not indicate that you have requested acupuncture treatment for chronic 
low back pain. Therefore, we decided that the Plan does not have to pre-approve acupuncture treatments.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 70450 billed for date of service May 28, 
2022. 
 You asked the Plan to pay for procedure code 70450. You say that the patient had multiple exams on this date 
of service. The Plan denied your request. The Plan says payment for code 70450 is bundled into payment for 
code 70496. 
 
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 
is a column II code to column I code 70496. 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 billed for date of service May 28, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a positron emission tomography (PET) scan. 
 
You asked the Plan to pre-approve the PET scan. You say that it is felt that this should be covered to make sure 
that there is no cancer. The Plan denied your request. The Plan says there is not sufficient evidence to support a 
suspicion of cancer in this case. A PET scan is not currently warranted. 
 
The Plan must follow Medicare rules. Medicare rules say that PET scans are covered only when they are 
medically necessary.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the PET scan. Our reviewer says that 
the requested imaging is not shown to be medically reasonable and necessary. Our physician reviewer found 
the enrollee has a history of ductal carcinoma in situ of the left breast, treated with lumpectomy on 5/15/2020. 
The enrollee has the impression that something is wrong and is concerned about a lump that she feels in the left 
upper outer breast area toward the axilla. Ultrasound of the right and left axillae on 5/31/22 showed 
morphologically normal lymph nodes and no suspicious findings. Digital 3-D tomosynthesis showed 
postoperative distortion and calcified fat necrosis in the left breast. Computed tomography (CT) imaging with 
contrast on June 16, 2022, showed no convincing evidence of interval progression of disease, with no new 
lymphadenopathy. Physical examination on 9/13/22 showed induration area in lateral upper area of breast that 
seems to be related to radiation therapy.  
 The rules say that PET scan for breast imaging is nationally non-covered for initial diagnosis and/or staging of 
axillary lymph nodes. It may be covered for initial disease only when malignancy is biopsy-proven or strongly 
suspected based on other testing. This is not documented in this case. 
 
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 PET scan have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a positron emission tomography (PET) scan.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 76705 billed for date of service June 2, 2022. 
 
You asked the Plan to pay for procedure code 76705. You say that the patient had multiple exams on this date 
of service. The Plan denied your request. The Plan says payment for code 76705 is bundled into payment for 
code 93976.  
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 76705 
is a column II code to column I code 93976. 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 76705 billed for date of service June 2, 2022.
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 March 17, 2022. 
 
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 March 
17, 2022.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for ambulance services provided on June 11, 2020. 
 
You asked the Plan to pay for the ambulance services. You say that the original claim submission was done 
timely. The Plan denied your request. The Plan says you did not timely file this corrected claim. 
 
The Plan must follow Medicare rules. Medicare rules say that may submit a corrected claim within 1 year from 
the date of the initial determination.  In this case, the Plan issued its initial denial of this claim on October 30, 
2020.  You did not submit a corrected claim until May 27, 2022, far outside of the 1-year filing limit. 
Therefore, we decided that the Plan does not have to pay for ambulance services provided on June 11, 2020.
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 April 26, 2022. 
 
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 April 
26, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an office visit to be provided by an out-of-network 
provider. 
 
You asked the Plan to pre-approve the office visit. You say that the services are medically necessary. The Plan 
denied your request. The Plan says the requested service is available 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 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 an out-of-network provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a shoulder orthosis (L3670) and a wrist-hand-finger orthosis 
(L3809) provided on May 8, 2022, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for the durable medical equipment (DME). You say that the services provided to the 
enrollee were for urgent care and should be paid. The Plan denied your request. The Plan says the claim 
processed correctly. The rendering provider is not a network provider, and the services were not referred by a 
network provider or rendered in an in-network facility. Furthermore, the Plan determined that the services were 
neither urgent nor emergent. The services at issue were not approved in advance and therefore, payment cannot 
be 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 shoulder orthosis (L3670) and a wrist-hand-
finger orthosis (L3809) provided on May 8, 2022, by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve specialist office visit to be provided by an out-of-
network (OON) provider. 
 
You asked the Plan to pre-approve specialist office visit. You say that you have seen the OON provider in 2020 
and would like to go back and see this provider. The Plan denied your request. The Plan says the service 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 items/services at issue in this appeal. We found no exception that would require 
the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve 
specialist office visit to be provided by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99100 billed for date of service May 25, 
2022. 
 
You asked the Plan to pay for procedure code 99100. You say that this code should be paid. The Plan denied 
your request. The Plan says procedure code 99100 is considered bundled and not separately payable. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate procedure code. 
 
We find that procedure code 99100 has a status indicator of B on the Physician Fee Schedule. This means that 
procedure code 99100 is not separately payable. Based on this information, we decided that Medicare rules for coverage of procedure code 99100 have not been met. Therefore, we decided that the Plan does not have to pay 
for procedure code 99100 billed for date of service May 25, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve additional transportation. 
 
You asked the Plan to pre-approve additional transportation. You say that you need transportation to dialysis. 
The Plan denied your request. The Plan says you have used 36 of the allowed 36 one-way trips this year. 
 
Medicare does not cover transport in a vehicle that is not an ambulance. However, the Plan offers a 
transportation benefit that exceeds Medicare coverage. For that reason, the Plans coverage rules apply in this 
case. The Plan covers a maximum of up to 36 one-way trips per year.  
 
 
 We looked at your request, the records in the case file, and the rules. Based on this information, we decided 
that you have exhausted the Plan maximum benefit for coverage of routine transportation. Therefore, we 
decided that the Plan does not have to pre-approve additional transportation.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for outpatient mental health services you received from a social 
worker on May 16, 2022. 
 
You asked the Plan to pay for the social worker services. You say that you have been seeing this provider for a 
while and you were not notified there would be a change in your coverage. The Plan denied your request. The 
Plan says you used a provider that is not eligible for Medicare. 
 
The Plan must follow Medicare rules. Medicare rules say that the only provider types eligible to provide 
Medicare-covered mental health services are as follows: Physicians, Clinical Psychologists, Clinical Social 
Workers, Clinical Nurse Specialists, Nurse Practitioners, Physician Assistants, Certified Nurse-Midwives, 
Independently Practicing Psychologists, and Certified Registered Nurse Anesthetists. The provider you saw for 
these services is a Social Worker, but not a Clinical Social Worker.  As a result, the provider does not meet 
Medicare criteria as a valid provider type for outpatient mental health services. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the social worker services have not been met. Therefore, we decided that the Plan does not have to 
pay for outpatient mental health services you received from a social worker on May 16, 2022.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to pay for code 99285 billed for date of service March 24, 2022. 
 
You asked the Plan to pay for code 99285. You say that the medical records support the code billed. The Plan 
denied your request. The Plan says the medical records do not support the date of service billed. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
In this case, the CPT Code Manual definition of code 99285 is emergency department visit for the evaluation 
and management of a patient (medical decision making of high complexity). 
 
We find that CPT code 99285 is not supported in the medical record. Specifically, the medical records you 
submitted explicitly state that the patient was seen on March 22, 2022.  However, you billed code 99285 for 
date of service March 24, 2022, which is not corroborated in the record.  While the code itself may be 
supported, the date of service billed is not. Based on this information, we decided that Medicare rules for coverage of code 99285 have not been met. Therefore, we decided that the Plan does not have to pay for code 
99285 billed for date of service March 24, 2022.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for emergency room visit provided on June 
13th, 2022. 
 
You asked the Plan to waive the copayment for emergency care. You say that you should not pay emergency 
room copayment since you were admitted to the hospital. The Plan denied your request. The Plan says this cost 
sharing was charged correctly. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay $120 for 
each Medicare-covered emergency room visit for emergency care. You were not admitted as an inpatient to this 
hospital; therefore, the emergency room copayment is not waived for this claim.  
 
You have been asked to pay $120 for each Medicare-covered emergency room visit for emergency care. This 
item/service falls within the emergency care benefit category. This means that you have been asked to pay the 
correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to 
pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment 
for emergency room visit provided on June 13th, 2022.