Persius/hicric huggingface dataset:
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a hospital bed provided on September 10, 2021, by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for a hospital bed. You say that you disagree with the denial of the claim payment 
for items ordered/purchased through an out-of-network provider. The Plan denied your request. The Plan says 
the provider is out-of-network and prior authorization was not found. 
 
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 hospital bed provided on September 10, 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 subsequent nursing facility care provided on March 30, 2022, 
by an out-of-network (OON) provider. 
 
You asked the Plan to pay for subsequent nursing facility care. You say that the rendering physician is a 
hospitalist physician with the group. You also say that the physician depends upon the hospital staff to verify 
eligibility and to obtain the proper authorization from the member's insurance company. The Plan denied your 
request. The Plan says services from non-participating providers are not covered 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 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 subsequent nursing facility care provided on 
March 30, 2022, by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the office visit (99214), therapeutic, prophylactic, or 
diagnostic injection (96372), and ketorolac tromethamine (J1885) provided on June 18, 2022. 
 
You asked the Plan to pay for the physician services. You say that you had severe tooth pain. You say that you 
went to urgent care. You also say that you are on a fixed income and cannot afford to pay this bill. The Plan 
denied your request. The Plan says the billed services are not covered for the diagnosis in this case. 
 
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 99214 is office or other outpatient visit for the evaluation 
and management of an established patient, which requires at least 2 of these 3 key components: A detailed 
history; A detailed examination; Medical decision making of moderate complexity. Counseling and/or 
coordination of care with other physicians, other qualified health care professionals, or agencies are provided 
consistent with the nature of the problem(s) and the patient's and/or family's needs. Usually, the presenting 
problem(s) are of moderate to high severity. Typically, 25 minutes are spent face-to-face with the patient 
and/or family. The CPT Code Manual definition of code 96372 is therapeutic, prophylactic, or diagnostic injection (specify substance or drug); subcutaneous or intramuscular. The CPT Code Manual definition of code 
J1885 is injection, ketorolac tromethamine, per 15 mg. 
 
We find that CPT codes 99214, 96372, J1885 are not supported in the medical record. Specifically, the services 
billed in this case are not coverable for routine dental care. Based on this information, we decided that 
Medicare rules for coverage of the physician services have not been met. Therefore, we decided that the Plan 
does not have to pay for the office visit (99214), therapeutic, prophylactic, or diagnostic injection (96372), and 
ketorolac tromethamine (J1885) provided on June 18, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to issue reimbursement for the physical or manipulative therapy 
performed for maintenance rather than restoration (S8990) provided from January 13, 2022, through April 7, 
2022. 
 
You asked the Plan to issue reimbursement for these services. You say that you are requesting a 
reconsideration of the Plan's denial for payment. The Plan denied your request. The Plan says these services are 
not covered by the Plan or by Medicare. 
 
The Plan must follow Medicare rules. The rules say that Medicare does not cover chiropractic maintenance 
care.  
 
We looked at the case file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of these services have not been met. Specifically, the services provided in this case were chiropractic 
maintenance care, which is not a covered benefit by the Plan or by Medicare. Therefore, we decided that the 
Plan does not have to issue reimbursement for the physical or manipulative therapy performed for maintenance 
rather than restoration (S8990) provided from January 13, 2022, through April 7, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an eye medical examination provided on July 18, 2022, by an 
out-of-network (OON) provider. 
 
You asked the Plan to pay for an eye medical examination. You say that a provider performing services in a 
nursing home is not responsible to obtain authorization. The Plan denied your request. The Plan says the 
services were billed by/rendered by/referred by non-participating providers. The Plan also says these services 
were not approved in advance. 
 
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 eye medical examination provided on July 18, 
2022, by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a rest home visit provided on May 23, 2022, by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for the rest home visit. You say that the nursing facility should be responsible for 
obtaining authorization. The Plan denied your request. The Plan says a referral/authorization was not obtained 
prior to rendering 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 a rest home visit provided on May 23, 2022, by an 
out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a specialist visit provided on April 26, 2022, by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for a specialist visit. You say that this should be a covered service The Plan denied 
your request. The Plan says you are out of network, and this was not an emergency visit. No referral on file. 
 
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 specialist visit provided on April 26, 2022, by an 
out-of-network (OON) provider.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for ambulance services (A0429RW) provided on April 16, 2022. 
 
You asked the Plan to pay for the ambulance services. You say that the services were medically necessary and 
correctly billed. The Plan denied your request. The Plan says the claim cannot be paid as 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. 
 
We find that CPT code A0429RW is not supported in the medical record. Specifically, "W" is not a valid 
destination modifier for this code. Based on this information, we decided that Medicare rules for coverage of 
the ambulance services have not been met. Therefore, we decided that the Plan does not have to pay for 
ambulance services (A0429RW) provided on April 16, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services provided on April 27, 2022. 
 
You asked the Plan to pay for the lab services. You say that these services were medically necessary and 
should be paid. 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, for 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 April 27, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an assessment of and care planning for a patient with 
cognitive impairment provided on March 31, 2022, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for an assessment of and care planning for a patient with cognitive impairment. You 
say that the services provided were medically necessary. The Plan denied your request. The Plan says the 
provider is out-of-network and authorization is required prior to an out-of-network visit. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 The requested provider in this case is not a network provider with the Plan. The Plan had network providers 
available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the 
item/service at issue. We found no exception that would require the Plan to pay for these items/services. 
Therefore, we decided that the Plan does not have to pay for an assessment of and care planning for a patient 
with cognitive impairment provided on March 31, 2022, by an out-of-network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 83789 billed for date of service April 12, 
2022. 
 
You asked the Plan to pay for procedure code 83789. You say that the services were medically necessary. The 
Plan denied your request. The Plan says payment for code 83789 is bundled into payment for code G0481.  
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 83789 
is a column II code to column I code G0481. 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 83789 billed for date of service April 12, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for anticoagulant management provided on June 17, 2022, by an 
out-of-network (OON) provider. 
 
You asked the Plan to pay for anticoagulant management. You say that you would like to request 
reconsideration of the denied claim. The Plan denied your request. The Plan says the provider is out-of-network 
and authorization is required prior to an out-of-network visit. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 The requested provider in this case is not a network provider with the Plan. The Plan had network providers 
available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the 
item/service at issue. We found no exception that would require the Plan to pay for these items/services. 
Therefore, we decided that the Plan does not have to pay for anticoagulant management provided on June 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 moderate sedation services rendered on April 26, 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 separately payable. 
 
The Plan must follow Medicare rules. The rules say that a professional component (PC)/technical component 
(TC) indicator of 3 represents TC only codes. 
 
We looked at the file and Medicare rules. Billed procedure code 99153 has a PC/TC indicator of 3 and no 
separate PC payment. Therefore, we decided that the Plan does not have to pay for the moderate sedation 
services rendered on April 26, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit and drug test provided on June 23, 2022, by an 
OON provider. 
 
You asked the Plan to pay for an office visit and drug test. You say that the plan participation was not 
necessary per the Plan provider representative. The Plan denied your request. The Plan says the out-of-network 
services were not authorized. 
 
 
 Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The requested provider in this case is not a network provider with the Plan. The Plan had network providers 
available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the 
item/service at issue. We found no exception that would require the Plan to pay for these items/services. 
Therefore, we decided that the Plan does not have to pay for an office visit and drug test provided on June 23, 
2022, by an OON provider.
Appeal type: Hospice
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the computed tomography (CT), abdomen and pelvis (74176) 
provided on January 10, 2022. 
 
You asked the Plan to pay for the CT. You say that the service was medically necessary at the time of service. 
The Plan denied your request. The Plan says the enrollees claim would be covered under Original Medicare as 
it is responsible for coverage of Part B benefits starting on the date of election until the last day of the month in 
which hospice is revoked. The Plan also says it is the providers responsibility to verify the enrollees coverage 
before rendering services and to know proper billing procedures for a Medicare Advantage member on hospice.  
Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice 
services. 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 the computed tomography (CT), abdomen and pelvis (74176) 
provided on January 10, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a travel case and a slim battery for a continuous positive 
airway pressure (CPAP) machine. 
 
You asked the Plan to pre-approve a travel case and a slim battery for a CPAP machine. You say that you 
would like the Plan to reconsider their denial. The Plan denied your request. The Plan says a travel case and a 
slim battery are not covered under Medicare or the Plan. 
 
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a 
medical purpose.   
 
The items at issue in this appeal do not serve a purpose that is primarily medical in nature. These items are 
available to the general public and would be helpful even to those who are not sick or injured. Therefore, we 
decided that the Plan does not have to pre-approve a travel case and a slim battery for a continuous positive 
airway pressure (CPAP) machine.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services provided on December 16, 2021 by a 
non-network 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 a non-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 referring provider 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 December 16, 2021 by a non-network provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that intensive physical, occupational and speech therapy 
services are needed to maximize the enrollee's function and independence with mobility and assisted daily 
living skills. The Plan denied your request. The Plan says based on Medicare guidelines the inpatient 
rehabilitation facility services you are requesting do not meet the requirements for approval. 
 
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 enrollee is living at home with history of below the knee amputation in 2020, 
heart disease, and high blood pressure. The enrollee was discharged from outpatient physical therapy on 
September 22, 2022 for meeting goals of therapy. Medical problems are stable. The request is for prosthetic 
fitting and training. There are no complex nursing or rehabilitation needs. While the enrollee has a need for 
physical or occupational therapy, there is no documentation of a need for an intensive rehabilitation program. 
 
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: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the Mass spectrometry and tandem mass spectrometry 
(83789) provided on May 11, 2022. 
 
You asked the Plan to pay for procedure code 83789. You say that you would like the Plan to reconsider their 
denial of payment. The Plan denied your request. The Plan says the services are not covered as billed. 
 
The Plan must follow Medicare rules. Medicare rules say that providers performing validity testing on urine 
specimens utilized for drug testing should not separately bill the validity testing. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of procedure code 83789 have not been met. Specifically, we find that the testing described by the 
billed code is considered specimen validity testing which is not separately payable. Therefore, we decided that 
the Plan does not have to pay for the Mass spectrometry and tandem mass spectrometry (83789) provided on 
May 11, 2022.