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

 
We decided that the Plan does not have to pay for an influenza vaccine and administration, and venipuncture 
provided on November 19, 2021, to December 2, 2021, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for an influenza vaccine and administration, and venipuncture. You say that you do 
not know why you are not contracted with this Plan. You also say that the Plan paid on previous claims for the 
exact same provider. The Plan denied your request. The Plan says you are a non-contracted provider with the 
Plan. The Plan also says that all services from a non-contracted provider require benefit certification from the 
Plan. 
 
 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 influenza vaccine and administration, and 
venipuncture provided on November 19, 2021, to December 2, 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 the initial nursing facility care (99304), and debridement 
services (11719, 11720) provided on January 19, 2022. 
 
You asked the Plan to pay for the physician services. You say that the nursing home ordered the physician to 
see the enrollee. You also say that the services were medically necessary. The Plan denied your request. The 
Plan says the claim processed correctly. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information. Your 
contract with the Plan says that there is $400 deductible which applies to Physician Services.  
 
The item or service you asked the Plan to pay for falls within the benefit category Physician Services. The Plan 
has followed Medicare rules by clearly disclosing in the contract that there is $400 deductible which applies to 
Physician Services. This cost sharing is a contractual obligation that had not been met at the time the physician services was received on January 19, 2022. Therefore, we decided that the Plan does not have to pay for the 
initial nursing facility care (99304), and debridement services (11719, 11720) provided on January 19, 2022.
Appeal type: Lab
Decision: Favorable

 
We decided that the Plan has to pay for StrataNGS testing (81479) provided on July 24, 2021. 
 
You asked the Plan to pay for StrataNGS. You say that this test was approved by the MolDX program and is 
medically necessary for this enrollee. The Plan denied your request. The Plan says that there are Medicare 
coverage determinations which indicate that panels including the FANCC and BLM genes are not covered. 
 
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 covered. This determination 
was made and is specific to the test at issue. Though this panel does include genes that another coverage rule 
indicates are non-covered, we find there is no basis to overrule the specific coverage decision made by the 
MolDX contractor for this particular test. Based on this information, we decided that Medicare rules for 
coverage of StrataNGS have been met. Therefore, we decided that the Plan has to pay for StrataNGS testing 
(81479) provided on July 24, 2021.  
 
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again 
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake 
and/or send us the new information. This does not happen often. If we decide to open the case again, we will 
send you a letter.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for laboratory services provided on April 12, 2022, by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for laboratory services. You say that you are appealing the claim payment denial. 
The Plan denied your request. The Plan says the services were provided out-of-network and were not approved 
in advanced. 
 
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 April 12, 2022, by 
an out-of-network (OON) provider.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve wireless capsule endoscopy (91110) for the enrollee. 
 
You asked the Plan to pre-approve these services. You say that a capsule study will allow us to avoid 
unnecessary endoscopy/anesthesia if no pathology is found. The Plan denied your request. The Plan says that 
your request is not medically necessary because records show the enrollee does not have evidence of upper and 
lower GI endoscopies within the past 12 months. 
 
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 requested services are not considered medically reasonable and necessary in this case. The enrollee does not 
have iron deficiency nor microcytosis. Further, the enrollee does not meet the criteria that an EGD and 
colonoscopy have been performed within the last 12 months. Our physician reviewer found that the enrollee's 
condition does not meet criteria for coverage of these 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 these services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve wireless capsule endoscopy (91110) for the enrollee.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a complete maxillary denture realignment (D5750) provided 
by an out-of-network provider on April 11, 2022. 
 
You asked the Plan to pay for a complete maxillary denture realignment. You say that these services were 
medically necessary. The Plan denied your request. The Plan says the rendered dental service is not a covered 
benefit. 
 
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 
complete maxillary denture realignment (D5750) provided by an out-of-network provider on April 11, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services provided on March 31, 2021. 
 
You asked the Plan to pay for the lab services. You say that you have provided medical records to support 
payment. The Plan denied your request. The Plan says you billed with an incorrect place of service on the 
claim. 
 
The Plan must follow Medicare rules. Medicare rules say that lab services, the POS code must reflect the 
location in which the sample was taken. POS code 81 is used to describe samples taken by the laboratory 
directly. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the lab services have not been met. Specifically, this claim was billed with the laboratory POS 
code. The records do not support that the sample was taken in a laboratory setting. Therefore, we decided that 
the Plan does not have to pay for lab services provided on March 31, 2021.
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 requested admission to an IRF is medically 
necessary. The Plan denied your request. The Plan says the requested admission to an IRF does not meet 
criteria. 
 
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 the complexity of your nursing, medical and rehabilitation needs do not require an 
acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. You were admitted for 
coronary artery bypass grafting. 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 not a reasonable expectation that you will be 
able to fully participate in and benefit from the intensive rehabilitation therapy program provided in an IRF. 
Medically necessary care can be provided in a different level of care. 
 
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: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 76770-26 billed for date of service February 
3, 2022. 
 
You asked the Plan to pay for procedure code 76770-26. You say that this is not a bundled charge. The Plan 
denied your request. The Plan says payment for code 76770-26 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 
76770-26 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 76770-26 billed for date of service 
February 3, 2022.
Appeal type: Hospice
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a driveline management kit provided on January 24, 2022. 
 
You asked the Plan to pay for the driveline management kit. The Plan denied your request. The Plan says 
original Medicare is responsible for payment. 
 
Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice 
services. Medicare hospice pays for claims related to the terminal illness. The rules say that the Plan may direct 
the provider to bill Medicare directly for these services.  
 The enrollee was under the Medicare hospice benefit for the dates of service at issue in this appeal. Therefore, 
we decided that the Plan does not have to pay for a driveline management kit provided on January 24, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay the provider for a crown - porcelain/ceramic (D2740) provided 
on January 25, 2022. 
 
You asked the Plan to pay the provider for the crown. You say that the provider should be paid for his services 
and you are grateful for his expertise. The Plan denied your request. The Plan says no prior authorization was 
received and the claim was denied as provider responsibility. 
 
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, prior authorization is required. 
Therefore, we decided that the Plan does not have to pay the provider for a crown - porcelain/ceramic (D2740) 
provided on January 25, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a rest home visit (99334) provided on October 24, 2021 by 
an out-of-network (OON) provider. 
 
You asked the Plan to pay for the rest home 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 a rest home visit (99334) provided on October 24, 
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 (81161, 81286, 81413, 81414, 81442, 81479) 
provided November 5, 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 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 for cardiovascular risk testing are non-covered for 
screening purposes. 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 (81161, 81286, 
81413, 81414, 81442, 81479) provided November 5, 2021.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a home health and skilled nursing visit provided on January 
5, 2022, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for a home health and skilled nursing visit. You say that this was initially billed to 
Medicare but was rejected because it was found out that the patient has a Medicare Secondary payer. The Plan 
denied your request. The Plan says there are no records of a prior authorization being obtained from the 
member's primary care physician (PCP) prior to services being provided by a non-contracted 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 a home health and skilled nursing visit provided 
on January 5, 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 provided on February 22, 2022. 
 
You asked the Plan to pay for the lab services. You say that you would like this claim reprocessed based on the 
medical records. The Plan denied your request. The Plan says you billed with an incorrect place of service on 
the claim. 
 
The Plan must follow Medicare rules. Medicare rules say that lab services, the POS code must reflect the 
location in which the sample was taken. POS code 81 is used to describe samples taken by the laboratory 
directly. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the lab services have not been met. Specifically, this claim was billed with the laboratory POS 
code. The records do not support that the sample was taken in a laboratory setting. Therefore, we decided that 
the Plan does not have to pay for lab services provided on February 22, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the molecular pathology services coded as 81455, 81479, 
81301 and 81194 provided on January 28, 2022 by an out-of-network (OON) provider. 
 
You asked the Plan to pay for the pathology services. You say that you are writing to appeal the decision to 
deny coverage of your genetic testing. The Plan denied your request. The Plan says enrollees must receive 
their medical services from an in-network provider with the exception being urgent or emergent services. Non-
emergent services with non-contracted providers require prior authorization before 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 the molecular pathology services coded as 81455, 
81479, 81301 and 81194 provided on January 28, 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 extra-spinal manipulation (98943), therapy technique 
(97530), mechanical traction (97012) and an office visit (99213) provided on April 8, 2022. 
 
You asked the Plan to pay for the manipulation, therapy, mechanical traction, and office visit. You say that you 
were given incorrect information about your chiropractor visits. The Plan denied your request. The Plan says 
you reached your maximum enhanced chiropractic services on your March 28, 2022, visit. 
 
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 Plan offers a chiropractic benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
  We looked at your request, the file, and rules. Based on this information we have determined that criteria for 
payment have not been met. Though the Plan offers a chiropractic 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 28, 2022. Therefore, we decided that the Plan does not have to pay for extra-spinal 
manipulation (98943), therapy technique (97530), mechanical traction (97012) and an office visit (99213) 
provided on April 8, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for genomic testing provided on February 7, 2022, by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for genomic testing. You say that this provider facility is an independent laboratory 
and does not have direct access or interaction with patients prior to performing the test. You also say that the 
treating physician determined that ordering the test is medically necessary for the patient to assist in treatment 
decisions. The Plan denied your request. The Plan says the member's primary care provider did not refer to the 
non-network provider for services. 
 
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 genomic testing provided on February 7, 2022, by 
an out-of-network (OON) provider.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a nursing facility visit provided on March 22, 2022, by an 
out-of-network (OON) provider. 
 
You asked the Plan to pay for the nursing facility visit. You say that the treatment provided to the enrollee was 
medically necessary and you would like the claim paid. The Plan denied your request. The Plan says the 
rendering provider is an OON provider and there are in-network providers available that provide the same 
quality of service. 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 a nursing facility visit provided on March 22, 
2022, by an out-of-network (OON) provider.