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

 
We decided that the Plan does not have to pre-approve office visit to be provided by an out-of-network (OON) 
provider. 
 
You asked the Plan to pre-approve office visit. You say that you are requesting reconsideration. The Plan 
denied your request. The Plan says the enrollees network primary care physician (PCP) or plan must give the 
enrollee approval in advance before they can use providers not in the plan's network. This is call giving them a 
"referral." 
 
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 
office visit to be provided by an out-of-network (OON) provider.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a surgical procedure of the eyes to be provided by an 
out-of-network (OON) provider. 
 
You asked the Plan to pre-approve a surgical procedure of the eyes. You say that you are requesting to see the 
out-of-network provider to address your advancing vision issues and you believe they are the best provider for 
your care. The Plan denied your request. The Plan says the requested services are able to be performed by a 
provider in-network. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pre-approve care from out-of-network providers only in cases involving 
emergencies, out of area urgent care and care that cannot be provided by network providers. 
 
The requested provider in this case is not a network provider with the Plan. The Plan has network providers 
available who can provide the 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 surgical procedure of the eyes 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 subsequent nursing care provided on June 23, 2022, by an 
out-of-network (OON) provider. 
 
You asked the Plan to pay for the subsequent nursing care. You say that the services were medically necessary, 
and the facility is responsible for obtaining authorization. The Plan denied your request. The Plan says the 
provider is out-of-network and authorization was not obtained prior to 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 subsequent nursing care provided on June 23, 
2022, by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a specialist office visit to be provided by an out-of-
network (OON) provider. 
 
You asked the Plan to pre-approve a specialist office visit. You say that you are appealing this denial. The Plan 
denied your request. The Plan says you generally must receive your care from a network provider. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pre-approve care from out-of-network providers only in cases involving 
emergencies, out of area urgent care and care that cannot be provided by network providers. 
 
The requested provider in this case is not a network provider with the Plan. The Plan has network providers 
available who can provide the items/services at issue in this appeal. We found no exception that would require 
the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve 
a specialist office visit to be provided by an OON provider.
Appeal type: SNF
Decision: Favorable

 
We decided that the Plan has to approve continued skilled nursing facility (SNF) services after 09/08/2022. 
 
You asked the Plan to approve SNF care. You say that the services should be covered as you disagree with the 
denial. The Plan denied your request. The Plan says that the SNF care is not medically necessary. 
 
The Plan must follow Medicare Rules. The rules say that Medicare plans must tell an enrollee that the Plan will 
stop paying for skilled nursing facility services. The Plan must issue a NOMNC no later than two days before 
the last covered day. This notice must include a description of the enrollee's right to an appeal. 
 
We looked at the file and the Medicare rules. The file does not show that a valid NOMNC was delivered two or 
more days before 09/08/2022. The Plan must pay for SNF services until the 100-day SNF care benefit is 
exhausted or daily skilled care is no longer needed and proper notice is issued. Therefore, we decided that the 
Plan has to approve continued skilled nursing facility (SNF) services after 09/08/2022.  
 
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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an electrocardiogram provided on August 18, 2022, by an 
out-of-network (OON) provider. 
 
You asked the Plan to pay for electrocardiogram. You say that the services were urgent and medically 
necessary. The Plan denied your request. The Plan says an authorization was not obtained prior to 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 an electrocardiogram provided on August 18, 
2022, by an out-of-network (OON) provider.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a home health aide. 
 
You asked the Plan to pre-approve home health aide. You say that no family can assist you. The Plan denied 
your request. The Plan says this aide is requested for help with personal care or housekeeping needs which is 
not covered by Medicare. 
 
The Plan must follow Medicare rules. The rules say that custodial care, which does not include services from 
trained medical or paramedical staff, is not covered.  
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of home health aide have not been met. Specifically, we find that the services at issue in this case are 
considered custodial in nature. Therefore, we decided that the Plan does not have to pre-approve a home health 
aide.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for mental health visit provided on February 
17, 2022. 
 
You asked the Plan to waive the copayment for mental health visit. You say that you only went over your 
medications so it shouldnt be so much. The Plan denied your request. The Plan says this cost sharing was 
charged correctly. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $20 
copayment for Outpatient mental health care. 
 
You have been asked to pay a $20 copayment for mental health visit. This item/service falls within the 
Outpatient mental health care benefit category. This means that you have been asked to pay the correct amount 
based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you 
enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for mental 
health visit provided on February 17, 2022.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Afrezza. 
 
You asked the Plan to pre-approve Afrezza. You say that Afrezza is medically necessary. The Plan denied your 
request. The Plan says this drug is not eligible for coverage under the Part B medical benefit. 
 
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-
administered drugs. The self-administered drugs requested here are not among the types which are covered by 
Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve Afrezza.  
 
Benefits for Afrezza may be available under Medicare Part D. Contact the Plan that administers Part D benefits 
for further information concerning any benefits and appeal rights.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the genetic testing provided on May 1, 2021, billed with 
codes 81220, 81225, 81226, 81227, 81230, 81240, 81241, 81291, 81335, 81355 and 81479. 
 
You asked the Plan to pay for the genetic testing billed. You say that this testing was necessary and should be 
paid. The Plan denied your request. The Plan says panel testing should be billed using one CPT code on the 
claim. 
 The Plan must follow Medicare rules. The rules say that if one laboratory procedure evaluates multiple genes 
using a next generation sequencing (NGS) procedure, the laboratory shall report only one unit of service of one 
genomic sequencing procedure, molecular multianalyte assay, multianalyte assay with algorithmic analysis, or 
proprietary laboratory analysis code. 
 
We looked at the file and Medicare rules. This was an NGS panel that was not billed with a single panel code 
as required. Based on this information, we decided that Medicare rules for coverage of the genetic testing billed 
have not been met. Therefore, we decided that the Plan does not have to pay for the genetic testing provided on 
May 1, 2021, billed with codes 81220, 81225, 81226, 81227, 81230, 81240, 81241, 81291, 81335, 81355 and 
81479.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for procedure code 11721 billed for date of service June 7, 2022.

You asked the Plan to pay for procedure code 11721. You say that the claim should be paid. The Plan denied your request. The Plan says payment for code 11721 is bundled into payment for code 11055.

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 11721 is a column II code to column I code 11055. 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 11721 billed for date of service June 7, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve arm pads and footrests/foot platform (K0108x3). 
 
You asked the Plan to pre-approve wheelchair accessories. You say that the enrollee needs the wheelchair with 
power tilt and all accessories requested. The Plan denied your request. The Plan says these items cannot be 
approved as they are already included with the approved power seating system and cannot be requested 
separately. 
 
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. Medicare rules confirm that the requested items are included with the 
power seat system, therefore, the items should not be requested separately. Based on this information, we 
decided that Medicare rules for coverage of wheelchair accessories have not been met. Therefore, we decided 
that the Plan does not have to pre-approve arm pads and footrests/foot platform (K0108x3).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for intraoral - periapical each additional radiographic image 
(D0230) provided on August 11, 2022. 
 
You asked the Plan to pay for the dental services. You say that the provider you went to is in-network so the 
services you received should be covered. The Plan denied your request. The Plan says your benefit for the 
requested item or service has already been exhausted. 
 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. This benefit includes the 
requested intraoral - periapical each additional radiographic image (D0230) but is limited to one procedure 
code per calendar year. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, certain limitations apply. The record 
shows your benefit for the requested intraoral - periapical first radiographic image (D0220) was exhausted on 
date of service August 11, 2022. The Plan agreed to cover intraoral - periapical first radiographic image 
(D0220), this is the one procedure code per calendar year. Therefore, we decided that the Plan does not have to 
pay for intraoral - periapical each additional radiographic image (D0230) provided on August 11, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 86077 billed for date of service July 9, 2022. 
 You asked the Plan to pay for procedure code 86077. You say that this service was medically necessary and 
should be paid. The Plan denied your request. The Plan says the number of units billed exceeds the maximum 
allowed. 
 
The Plan must follow Medicare rules. Medicare rules say that claims submitted where the unit of service 
exceeds the MUE value cannot be paid when the MAI value is 2.  
 
In this case, the MUE for CPT code 86077 is 1. The MAI value for this code is 2. You billed 2 units of this 
code, exceeding the MUE. Based on this information, we decided that Medicare rules for coverage of 
procedure code 86077 have not been met. Therefore, we decided that the Plan does not have to pay for 
procedure code 86077 billed for date of service July 9, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 81345 billed for date of service June 28, 
2022. 
 You asked the Plan to pay for procedure code 81345. You say that the services at issue were a medical 
necessity for the enrollee. The Plan denied your request. The Plan says payment for code 81345 is bundled into 
payment for code 0089U. 
 
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 81345 
is a column II code to column I code 0089U. 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 81345 billed for date of service June 28, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the genetic testing provided on July 21, 2022, billed with 
codes 87653, 87481, 87798, 87640 and 87500. 
 
You asked the Plan to pay for the genetic testing billed. You say that the services at issue have been billed 
correctly. The Plan denied your request. The Plan says panel testing should be billed using one CPT code on 
the claim. 
 The Plan must follow Medicare rules. The rules say that if one laboratory procedure evaluates multiple genes 
using a next generation sequencing (NGS) procedure, the laboratory shall report only one unit of service of one 
genomic sequencing procedure, molecular multianalyte assay, multianalyte assay with algorithmic analysis, or 
proprietary laboratory analysis code. 
 
We looked at the file and Medicare rules. This was an NGS panel that was not billed with a single panel code 
as required. Based on this information, we decided that Medicare rules for coverage of the genetic testing billed 
have not been met. Therefore, we decided that the Plan does not have to pay for the genetic testing provided on 
July 21, 2022, billed with codes 87653, 87481, 87798, 87640 and 87500.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the paring or cutting of benign hyperkeratotic lesion (eg, 
corn or callus) (11056) provided July 19, 2022. 
 
You asked the Plan to pay for the foot care. You say that you object to the denial for foot care that you received 
for removal of lesions that had become very painful and had limited your ability to continue normal activities. 
Your primary care physician referred you to the podiatrist. The Plan denied your request. The Plan says this is 
considered routine foot care in the absence of a comorbid condition that severely impacts circulation in lower 
extremities and is not covered by Medicare. 
 
The Plan must follow Medicare rules. The rules say that routine foot care is not covered. The only exception is 
for those who have a condition that results in severe loss of circulation or areas of poor sensation in the legs or 
feet or have fungal nails.  
 
Records do not show that any of these conditions are present. The services you are asking the Plan to pay for 
are routine foot care services. Based on this information, we decided that Medicare rules for coverage of the 
foot care have not been met. Therefore, we decided that the Plan does not have to pay for the paring or cutting 
of benign hyperkeratotic lesion (eg, corn or callus) (11056) provided July 19, 2022.
Appeal type: Hospice
Decision: Unfavorable

 
We decided that the Plan does not have to pay for skilled nursing facility (SNF) services provided from 
November 17, 2021, to November 30, 2021 and December 15, 2021, to December 23, 2021. 
 
You asked the Plan to pay for SNF services. You say that the SNF services were medically necessary. The Plan 
denied your request. The Plan says the member had hospice in November 2021, therefore the services should 
be billed to Traditional Medicare. Additionally, the member exhausted the SNF benefit effective 
December 15, 2021. 
 
Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice 
services. Original Medicare is responsible for payment for services until the first day of the month after the 
hospice election has been revoked or terminated. 
 
The enrollee ended Medicare Hospice benefits on November 9, 2021. The services in question were provided 
before the end of that month. Therefore, we decided that the Plan does not have to pay for skilled nursing 
facility (SNF) services provided from November 17, 2021, to November 30, 2021. 
 
The Plan must follow Medicare rules. The rules say that enrollees are covered for up to 100 days of skilled care 
in a SNF in each benefit period. A benefit period begins on admission to a hospital or to SNF level of care and 
ends when the enrollee has gone 60 days in a row without inpatient hospital or SNF care. 
 
The file shows that the enrollee received 100 days of SNF care during the benefit period from June 20, 2021 to 
December 14, 2021. The Plan has covered 100 days of SNF care.  
 
Although the enrollee may still need skilled care, the Plan is not required to pay for more than 100 days of SNF 
coverage during this benefit period. The enrollee will be eligible for a new benefit period when the enrollee has 
not been receiving care in a hospital or skilled care in a SNF for at least 60 days in row. Therefore, we decided 
that the Plan does not have to pay for the SNF services provided from December 15, 2021, to  
December 23, 2021.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to pay for hospital discharge day management (CPT code 99239) 
provided on March 11, 2022. 
 
You asked the Plan to pay for the service. You say that the claim should be paid. The Plan denied your request. 
The Plan says the service is not supported by the records. 
 
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 99239 is hospital discharge day management; more than 
30 minutes. 
 
We find that CPT code 99239 is hospital discharge day management; more than 30 minutes is not supported in the medical record. Specifically, the documentation provided did not verify this service was performed. Based 
on this information, we decided that Medicare rules for coverage of the service have not been met. Therefore, 
we decided that the Plan does not have to pay for hospital discharge day management (CPT code 99239) 
provided on March 11, 2022.