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

We decided that the Plan does not have to pay for an office visit (99213), a methylprednisolone acetate
injection (96372, J1030), and a ketorolac tromethamine injection (96372, J1885) provided on July 23, 2021, by
an out-of-network (OON) provider.
You asked the Plan to pay for an office visit, a methylprednisolone acetate injection, and a ketorolac
tromethamine injection. You say that had you been aware, you would have obtained the necessary
authorization. The Plan denied your request. The Plan says prior authorization was not obtained by the provider
and the plan has confirmed that the member does not meet one of the exceptions, which include an ambulance
service, emergency and urgently needed, post stabilization care, nor dialysis while outside of the service area.
The Plan also states that both the rendering provider and the referring provider are non-participating providers.
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 (99213), a methylprednisolone
acetate injection (96372, J1030), and a ketorolac tromethamine injection (96372, J1885) provided on July 23,
2021, by an out-of-network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the drug test (G0482) rendered by the out-of-network (OON)
provider on January 22, 2021.
You asked the Plan to pay for this service. You say that you are requesting a reconsideration of the Plan's
denial for payment. The Plan denied your request. The Plan says the service was rendered by an out of network
provider, without prior 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 provider in this case is not a network provider with the Plan. The Plan had network providers available
who could have provided the service at issue in this appeal. The Plan did not pre-approve the service at issue.
We found no exception that would require the Plan to pay for this service. Therefore, we decided that the Plan
does not have to pay for the drug test (G0482) rendered by the out-of-network (OON) provider on January 22,
2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for a dental tissue examination received on September 14, 2021.

You asked the Plan to pay for the services. You say that the physician who provided this service assured you that it was medically necessary and would be covered. The Plan denied your request. The Plan says the services are not a covered benefit.

Medicare generally does not cover dental services. The Plan follows the same rule. 

The services you are asking the Plan to pay for involve the care, treatment, filling, removal or replacement of your teeth or the structures directly supporting your teeth. These are dental services that are not covered or paid for by Medicare. Therefore, we decided that the Plan does not have to pay for a dental tissue examination received on September 14, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services rendered on July 2, 2020.
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your
request. The Plan says the services are not billed correctly.
The Plan must follow Medicare rules. Medicare rules say that claims must be billed with the correct place of
service (POS) code.
We looked at the file and Medicare rules. The claim for these services was billed with POS code 81 for a
laboratory setting; however, the file shows that the specimen was obtained in an office setting and should have
been billed with POS code 11. Therefore, we decided that the Plan does not have to pay for the laboratory
services rendered on July 2, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for physical therapy services (97110, 97112, 97535) provided on
March 11, 2021, by an OON provider.
You asked the Plan to pay for physical therapy. You say that you want the Plan to reconsider the payment for
the claims sine you were never informed about being out-of-network or prior authorization requirements. You
also say that if you had known, you would have filed the authorization to avoid this issue. The Plan denied your
request. The Plan says this provider is a non-participating provider with the Plan and the referring provider is
also a non-participating provider. The Plan also says that they did not authorize any services for this 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 physical therapy services (97110, 97112, 97535)
provided on March 11, 2021, by an OON provider.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pay for the romosozumab-aqqg injection rendered on August 2,
2021.
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your
request. The Plan says the billed diagnosis is not supported.
The Plan must follow Medicare rules. The rules say that claims must be billed with the most precise diagnosis
code.
We looked at the file and Medicare rules. The file shows that the billed diagnosis code is not appropriate for the
enrollee. 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 romosozumab-aqqg injection
rendered on August 2, 2021.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan does not have to pay for outpatient mental health services provided to the enrollee on
September 30, 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 these 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 outpatient mental health services provided to the
enrollee on September 30, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for a device evaluation (G2066) provided on September 7, 2021,
by an out-of-network (OON) provider.
You asked the Plan to pay for a device evaluation. You say that this is supported in the records. The Plan
denied your request. The Plan says this was 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 device evaluation (G2066) provided on
September 7, 2021, by an out-of-network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the intermittent urinary catheter (A4351), provided on March
4, 2021 by an out-of-network (OON) provider.
You asked the Plan to pay for the intermittent urinary catheter. You say that the item is medically necessary.
The Plan denied your request. The Plan says the item was obtained out-of-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 the intermittent urinary catheter (A4351), provided
on March 4, 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 injection(s), anesthetic agent(s) and/or steroid; genicular
nerve branches, including imaging guidance, when performed (CPT code 64454) provided to the enrollee on
July 8, 2021.
You asked the Plan to pay for the injection. You say that the clinical reports clearly demonstrate medical
necessity for the pain management treatment. The Plan denied your request. The Plan says experimental or
investigational services are not covered.
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 injection. Our reviewer says that the
requested items/services are not considered medically reasonable and necessary in this case.
Our physician reviewer found genicular nerve blocks and genicular nerve radiofrequency ablation are
considered investigational and not medically necessary for the treatment of chronic knee pain, including, but
not limited to any of the following: degenerative joint disease; osteoarthritis of the knee; as a treatment prior to
knee replacement; as a treatment following knee replacement; or as a treatment for individuals who are not
candidates for knee replacement surgery. The review has determined that the requested genicular nerve block
of the left knee is not medically reasonable or 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 the injection have not been met. Therefore, we decided that the Plan does not
have to pay for the injection(s), anesthetic agent(s) and/or steroid; genicular nerve branches, including imaging
guidance, when performed (CPT code 64454) provided to the enrollee on July 8, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the office visit (99212) rendered by the out-of-network
(OON) provider on July 23, 2021.
You asked the Plan to pay for this service. You say that you are requesting a reconsideration of the Plan's
denial for payment. The Plan denied your request. The Plan says the service was rendered by an out of network
provider, without prior 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 provider in this case is not a network provider with the Plan. The Plan had network providers available
who could have provided the service at issue in this appeal. The Plan did not pre-approve the service at issue.
We found no exception that would require the Plan to pay for this service. Therefore, we decided that the Plan
does not have to pay for the office visit (99212) rendered by the out-of-network (OON) provider on July 23,
2021.
Appeal type: Hospice
Decision: Unfavorable

We decided that the Plan does not have to pay for long term hospice care provided from June 1, 2021, through
June 30, 2021.
You asked the Plan to pay for long term hospice care. The Plan denied your request. The Plan says procedure
code T2046 is not valid for Medicare purposes.
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 long term hospice care provided from June 1, 2021, through
June 30, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for electrical stimulation (G0283) physical performance test or
measurement (97750) range of motion measurements and report (separate procedure) (95851) therapeutic
procedure (97110) unlisted therapeutic procedure (97139) subcutaneous and intramuscular injection (96372)
unclassified drug (J3490) thiamine injection, 100 mg (J3411) pyridoxine injection, 100 mg (J3415)
compounded drug, not otherwise classified (J7999) provided on March 8, 2021 by an out-of-network (OON)
provider.
You asked the Plan to pay for the outpatient services. You say that the medical records provided support the
necessity of the services in dispute. The Plan denied your request. The Plan says these services are not covered
by Medicare or the Plan. Enrollee's 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. Review of the file and publicly available records, we find that the physical therapy
services at issue in this case were rendered by an NP/PA who is not licensed to provide physical therapy in the
State of Oklahoma. The multiple drug codes reported on this claim refer to a pre-filled compounded
drug/vitamin syringe. The rules require that any compounded drug be billed using the not otherwise classified
code J7999. As this compounded drug was not billed properly, payment cannot be made. Because the drugs are
not paid as billed, the drug administration code, 96372, also cannot be paid. 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
electrical stimulation (G0283) physical performance test or measurement (97750) range of motion
measurements and report (separate procedure) (95851) therapeutic procedure (97110) unlisted therapeutic
procedure (97139) subcutaneous and intramuscular injection (96372) unclassified drug (J3490) thiamine
injection, 100 mg (J3411) pyridoxine injection, 100 mg (J3415) compounded drug, not otherwise classified
(J7999) provided on March 8, 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 an Intracept procedure.
You asked the Plan to pre-approve an Intracept procedure. You say that this service is medically necessary. The
Plan denied your request. The Plan says this service is considered experimental.
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 an Intracept procedure. Our reviewer
says that the requested items/services are not considered medically reasonable and necessary in this case. Our
physician reviewer found the Intracept procedure is experimental. More research is needed to show safety and
efficacy.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of an Intracept procedure have not been met. Therefore, we decided that the Plan
does not have to pre-approve an Intracept procedure.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the ultrasound, abdominal, real time with
image documentation; limited (76705) provided July 30, 2021.
You asked the Plan to waive the copayment for the ultrasound. You say that you want the Plan to cover their
share of the service. The Plan denied your request. The Plan says the copayment was applied 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 a $110
copayment for Medicare-covered radiological diagnostic services, not including X-rays, performed in a
physician's office or at a free-standing facility.
You have been asked to pay a $61.16 copayment for the ultrasound. The ultrasound falls within the Outpatient
diagnostic tests and therapeutic services and supplies benefit category. This means that you have been asked to
pay less than or equal to 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 the ultrasound, abdominal, real time with image documentation;
limited (76705) provided July 30, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a primary care referral to an out-of-network provider for the enrollee.
You asked the Plan to pre-approve the referral. You say that this is medically necessary. The Plan denied your request. The Plan says the enrollee must choose an in-network provider to be a primary care 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 a primary care referral to an out-of-network provider for the enrollee.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pay for neuromonitoring services (95907, 95886, 95938) provided
June 23, 2021.

You asked the Plan to pay for neuromonitoring services. You say that the services were medically necessary.
The Plan denied your request. The Plan says the provider at issue is not eligible for separate payment.

The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly.
Providers must report services with the appropriate CPT code.

We find that CPT code 95907, 95886, & 95938 is not supported in the medical record. Specifically, payment
for this service must be made to the facility. The provider at issue does not have a taxonomy that is valid for
Medicare payment. Based on this information, we decided that Medicare rules for coverage of neuromonitoring
services have not been met. Therefore, we decided that the Plan does not have to pay for neuromonitoring
services (95907, 95886, 95938) provided June 23, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the coronavirus testing provided on October 12, 2021.
You asked the Plan to pay for the testing services. You say that you should be reimbursed the full amount. The
Plan denied your request. The Plan says you were paid the allowed amount.
The Plan must follow Medicare rules. Medicare rules say a bill for assigned services is considered paid in full
when the Medicare allowed amount is paid.
In this case, the records show that the Plan has paid for the services at issue based on the Medicare allowed
amount. Therefore, we decided that the Plan does not have to pay for the coronavirus testing provided on
October 12, 2021.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care.
You asked the Plan to pre-approve SNF care. You say that SNF care is medically necessary. The Plan denied
your request. The Plan says the enrollee does not meet Medicare criteria for coverage of SNF care.
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors
listed in the Medicare rules section are met. Custodial care is 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 SNF care. Our reviewer says that daily
skilled services are not necessary. Our physician reviewer found based on the medical records provided this
patient does not require the services on an inpatient basis, only in a skilled nursing facility setting. Records
indicate the patient is participating in and benefiting from treatment in the rehabilitation facility. Continued
care in the acute inpatient rehabilitation facility is appropriate until the patient is stable to transfer to a lower
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 SNF care have not been met. Therefore, we decided that the Plan does not have
to pre-approve skilled nursing facility (SNF) care.