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

 
We decided that the Plan does not have to pay for physician's services provided on March 23, 2022. 
 
You asked the Plan to pay for the physician's services. The Plan denied your request. 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 and we 
determined that these services did not involve an emergency or out of area urgent care.  
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The requested provider in this case is not a network provider with the Plan. The Plan did not pre-approve the 
services at issue. We found no exception that would require the Plan to pay for these services. Therefore, we 
decided that the Plan does not have to pay for physician's services provided on March 23, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the continuous glucose monitor (CGM) supplies rendered on 
April 15, 2022. 
 
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 type and quantity of items is not substantiated. 
 
The Plan must follow Medicare rules. Medicare rules say that a standard written order (SWO) is required for all 
durable medical equipment (DME) and supplies. 
 We looked at the file and Medicare rules. The file shows that there is no valid SWO supporting the billed 
supplies. Therefore, we decided that the Plan does not have to pay for the continuous glucose monitor (CGM) 
supplies rendered on April 15, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for domiciliary or rest home visit provided on January 5, 2022. 
 
You asked the Plan to pay for domiciliary or rest home visit. The Plan denied your request. The Plan says 
services from non-par providers are not covered under an HMO plan unless preauthorized. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The requested provider in this case is not a network provider with the Plan. The Plan did not pre-approve the 
services at issue. We found no exception that would require the Plan to pay for these services. Therefore, we 
decided that the Plan does not have to pay for domiciliary or rest home visit provided on January 5, 2022.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 97010P billed for date of service June 28, 
2021. 
 
You asked the Plan to pay for procedure code 97010P. You say that you have provided records to support 
payment. The Plan denied your request. The Plan says procedure code 97010P 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 97010P has a status indicator of B on the Physician Fee Schedule. This means that 
procedure code 97010P is not separately payable. Based on this information, we decided that Medicare rules 
for coverage of procedure code 97010P have not been met. Therefore, we decided that the Plan does not have 
to pay for procedure code 97010P billed for date of service June 28, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a follow up office visit to be provided by an out-of-
network (OON) provider. 
 
You asked the Plan to pre-approve a follow up office visit to be provided by an OON provider. You say that 
the services are necessary. The Plan denied your request. The Plan says there are in-network providers that are 
able to provide these services. Therefore, coverage criteria have not been met. 
 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 follow up 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 the anesthesia services coded 00811 provided on February 
25, 2022. 
 
You asked the Plan to pay for the anesthesia services. You say that you disagree with the Plan's denial. The 
Plan denied your request. The Plan says the services billed are 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 CPT code. 
 
In this case, the CPT Code Manual definition of code 00811 is anesthesia for lower intestinal endoscopic 
procedures, endoscope introduced distal to duodenum; not otherwise specified. 
 
We find that CPT code 00811 is not supported in the medical record. Specifically, only the anesthesia service 
which has the highest base unit value should be reported. Review of the file shows that code 00790 (Anesthesia 
for intraperitoneal procedures in upper abdomen including laparoscopy; not otherwise specified) was also 
billed and paid by the Plan. This means this code is not separately payable. Based on this information, we 
decided that Medicare rules for coverage of the anesthesia services have not been met. Therefore, we decided 
that the Plan does not have to pay for the anesthesia services coded 00811 provided on February 25, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the anesthesia services rendered on February 24, 2022. 
 
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 file shows that the services were performed in the outpatient 
setting and were incorrectly billed with inpatient POS code 21. Therefore, we decided that the Plan does not 
have to pay for the anesthesia services rendered on February 24, 2022.
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 February 28, 
2022. 
 
You asked the Plan to pay for procedure code 99100. You say that this code is separately payable. 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 99100 has a Status Indicator of I on the Physician Fee Schedule. This means that 
procedure code 99100 is not valid for Medicare purposes. 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 February 28, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the diabetes outpatient self-management training services 
provided on March 17, 2022 by an out-of-network (OON) provider. 
 
You asked the Plan to pay for the diabetes outpatient self-management training services. You say that you 
disagree with the Plan's denial. The Plan denied your request. The Plan says the rendered services are not a 
covered benefit. 
 
 
 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 diabetes outpatient self-management training 
services provided on March 17, 2022 by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the rest home visit provided on May 5, 2022 by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for the rest home visit. You say that you disagree with the Plan's denial. The Plan 
denied your request. The Plan says the services rendered are not a covered benefit. 
 
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 rest home visit provided on May 5, 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 subsequent hospital care (99232) provided on March 11, 
2022. 
 
You asked the Plan to pay for subsequent hospital care. You say that you have provided records to support the 
service billed. The Plan denied your request. The Plan says payment for the service at issue is included in the 
payment for procedure code 32551. 
 
The Plan must follow Medicare rules. Medicare rules say that generally E&M services on the same date of 
service as a minor surgical procedure are included in the payment for the procedure. 
 
We find that separate payment for E&M code 99232 is not supported. Specifically, the service at issue was 
reported on the same date of service as a minor surgical procedure. The service at issue was not billed with an 
appropriate modifier to indicate that it is separately reportable. Based on this information, we decided that Medicare rules for coverage of subsequent hospital care. have not been met. Therefore, we decided that the 
Plan does not have to pay for subsequent hospital care (99232) provided on March 11, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the unlisted molecular pathology procedure (81479-59) 
billed for August 31, 2021. 
 
You asked the Plan to pay for the pathology procedure. You say that this service was billed correctly and is 
supported in the medical record. The Plan denied your request. The Plan says this claim was not billed in 
accordance with Medicare rules. 
 
The Plan must follow Medicare rules. The rules state that providers may bill services with a -59 modifier if the 
service billed with the modifier indicates a distinct procedural service.   
 
The medical records provided do not show that the service billed with the -59 modifier is a distinct procedural 
service. Specifically, the records do not indicate that there was more than one specimen, or more than one panel 
provided for this specimen. The use of the 59 modifier in this case is unclear. Based on this information, we 
decided that Medicare rules for coverage of services billed with a -59 modifier have not been met. Therefore, 
we decided that the Plan does not have to pay for the unlisted molecular pathology procedure (81479-59) billed 
for August 31, 2021.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the ambulance services. 
 
You asked the Plan to waive the copayment for the ambulance services. You say that you should not have to 
pay this copayment. The Plan denied your request. The Plan says you were charged this cost sharing 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 $240 
copayment for each ambulance trip. You had 1 ambulance trip(s). The Plan charged you $240 for these 
services. 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 the ambulance services.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the physician services provided on May 5, 2021 by an out-
of-network (OON) provider. 
 
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 were 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 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 physician services provided on May 5, 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 a domiciliary or rest home visit provided on July 8, 2021, by 
an out-of-network (OON) provider. 
 
You asked the Plan to pay for a domiciliary or rest home visit. You say that the provider has no prior 
knowledge of which patients he/she will be required to see. You also say that once the provider arrives at the 
facility, he/she receives a list of patients who require treatment and provides services to all of them, since there 
is currently no in-network doctor who can treat the patients in this facility. The Plan denied your request. The 
Plan says this provider is out-of-network with the Plan. The Plan also says that authorization was not obtained 
prior to the 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 a domiciliary or rest home visit provided on July 
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 chiropractic services. 
 
You asked the Plan to pre-approve chiropractic services. You say that this care is medically necessary for your 
condition. The Plan denied your request. The Plan says the criteria for chiropractic services have not been met. 
 
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.  
 
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 chiropractic services Our reviewer says 
that the requested chiropractic services are not medically reasonable and necessary. Our physician reviewer 
found that the record indicates that you have thoracic back pain. The record does not document a subluxation 
shown by either x-ray or physical exam. The elements of the coverage criteria are not satisfied. The requested 
service is not recommended. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of chiropractic services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve chiropractic services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve durable medical equipment (DME), miscellaneous 
(E1399) 
 
You asked the Plan to pre-approve miscellaneous DME. You say that the requested special mattress is needed, 
and you are requesting reconsideration. The Plan denied your request. The Plan says the requested code E1399 
does not meet the required coding guidelines and there is no care plan established for you. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of miscellaneous DME, special mattress, have not been met. Specifically, Medicare rules state that 
code E1399 does not meet the required coding guidelines and are denied as not reasonable and necessary. 
Therefore, we decided that the Plan does not have to pre-approve durable medical equipment (DME), 
miscellaneous (E1399)
Appeal type: Step-Therapy
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Euflexxa. 
 
You asked the Plan to pre-approve Euflexxa. 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. 
 
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 Euflexxa. Our reviewer says that the 
services are not medically necessary. Our physician reviewer found the record does not indicate that the 
enrollee has a contraindication to, or would have an adverse effect from the plan's preferred step one 
alternative. The elements of the coverage criteria are not satisfied. The requested service cannot be 
recommended. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Euflexxa have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Euflexxa.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the rest home visit provided on February 15, 2022 by an out-
of-network (OON) provider. 
 
You asked the Plan to pay for the rest home visit. You say that you disagree with the Plan's denial. The Plan 
denied your request. The Plan says the services billed are not a covered benefit. 
 
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 rest home visit provided on February 15, 2022 
by an out-of-network (OON) provider.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve transcatheter insertion or replacement of permanent 
leadless pacemaker. 
 
You asked the Plan to pre-approve transcatheter insertion or replacement of permanent leadless pacemaker. 
You say that the services are necessary. The Plan denied your request. The Plan says you are not enrolled in a 
clinical study. Therefore, coverage criteria are not met. 
 
The Plan must follow Medicare rules. Medicare rules say that CMS covers leadless pacemakers when 
procedures are performed in Food and Drug Administration (FDA) approved studies. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of transcatheter insertion or replacement of permanent leadless pacemaker have not been met. 
Therefore, we decided that the Plan does not have to pre-approve transcatheter insertion or replacement of 
permanent leadless pacemaker.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services provided on May 19, 2022 by an out-
of-network (OON) provider. 
 
You asked the Plan to pay for the laboratory services. You say that you disagree with the Plan's denial. The 
Plan denied your request. The Plan says the services provided are not a covered benefit. 
 
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 services provided on May 19, 2022 
by an out-of-network (OON) provider.