Persius/hicric huggingface dataset:
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services provided on July 7, 2022, by an out-
of-network (OON) provider. 
 
You asked the Plan to pay for the laboratory services. You say that you are appealing the denied claim. The 
Plan denied your request. The Plan says the rendering and referring providers are both OON providers and 
there was no approved authorization. Also, the service rendered was not urgent or emergent. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
  The requested provider in this case is not a network provider with the Plan. The Plan had network providers 
available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the 
item/service at issue. We found no exception that would require the Plan to pay for these items/services. 
Therefore, we decided that the Plan does not have to pay for the laboratory services provided on July 7, 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 subsequent nursing facility care (99308) provided on 
February 9, 2022, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for the nursing facility care. You say that the provider relies on the facility staff to 
verify eligibility and to obtain the proper authorization. The Plan denied your request. The Plan says prior 
authorization was not obtained before the service was 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 provider in this case is not a network provider with the Plan. The Plan did not pre-approve the service 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 the subsequent nursing facility care (99308) provided on February 9, 2022, by 
an out-of-network (OON) provider.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for emergency room services on July 03, 2022, 
to July 05, 2022. 
 
You asked the Plan to waive the copayment for emergency room services. You say that you want to appeal the 
amount being charged. 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 $90 
copayment for emergency room. Emergency care refers to services that are furnished by a provider qualified to 
furnish emergency services, and needed to evaluate or stabilize an emergency medical condition. 
 
You have been asked to pay a $90 copayment for emergency room services. This item/service falls within the 
Emergency 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 emergency room 
services on July 03, 2022, to July 05, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the tetanus vaccine (90714) and administration (90417) 
provided on July 26, 2022. 
 
You asked the Plan to pay for the immunization. You say that you received a notification that you were due for 
a tetanus shot. You also say that you do not understand why this is not covered. The Plan denied your request. 
The Plan says this immunization is not covered under Medicare Part B. 
 
In the absence of injury or direct exposure to illness, Medicare does not pay for or provide the immunization. 
The Plan follows the same rules.  
 
Records do not show that you have been injured or directly exposed to any illness related to the immunization. 
Therefore, we decided that the Plan does not have to pay for the tetanus vaccine (90714) and administration 
(90417) provided on July 26, 2022.  
 
Benefits for the immunization 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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code A4930 provided on July 5, 2022. 
 
You asked the Plan to pay for procedure code A4930. You say that this service was medically necessary. The 
Plan denied your request. The Plan says this code is 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. 
 
We find that CPT code A4930 is not supported in the medical record. Specifically, this code has a status 
indicator of "N" and is not separately payable. Based on this information, we decided that Medicare rules for 
coverage of procedure code A4930 have not been met. Therefore, we decided that the Plan does not have to 
pay for procedure code A4930 provided on July 5, 2022.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 76705 billed for date of service June 29, 
2022. 
 
You asked the Plan to pay for procedure code 76705. You say that this should be paid for. The Plan denied 
your request. The Plan says payment for code 76705 is bundled into payment for code 93976. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. In this case, we have confirmed that code 76705 
is a column II code to column I code 93976. This claim has not been billed with an appropriate modifier to bypass the edit. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we 
decided that the Plan does not have to pay for procedure code 76705 billed for date of service June 29, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for inpatient hospital care provided on April 
14, 2022, to April 20, 2022. 
 
You asked the Plan to waive the copayment for inpatient hospital care. You say that you are disputing the share 
cost. 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 $260 
copayment per day for days 1 to 6 for inpatient hospital care. This inpatient hospital stay lasted 6 days, 
resulting in a copayment of $1,560 ($260 per day for 6 days = $1,560). 
 
You have been asked to pay $260 copayment per day for days 1 to 6 for inpatient hospital care. This 
item/service falls within the inpatient hospital 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 inpatient hospital care provided on April 14, 2022, to April 20, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the debridement of nails provided on June 15, 2022, by an 
out-of-network (OON) provider. 
 
You asked the Plan to pay for the debridement of nails. You say that the member is a resident in a nursing 
home and has an authorization on file for all care at the facility, including consultations. The Plan denied your 
request. The Plan says services from non-participating providers are not covered under your plan unless they 
are authorized by the Plan before the services are provided. 
 
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 debridement of nails provided on June 15, 
2022, by an out-of-network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the PrismRA testing provided on March 1, 2022. 
 
You asked the Plan to pay for the PrismRA testing. You say that this test is medically necessary. The Plan 
denied your request. The Plan says there is not enough information to approve this testing. 
 
The Plan must follow Medicare rules. Medicare rules say that Medicare nationally covers FDA-approved NGS 
testing, when the test is FDA approved. 
 
We looked at the file and Medicare rules. Research shows that the PrismRA test is not FDA approved. Based 
on this information, we decided that Medicare rules for coverage of the PrismRA testing have not been met. 
Therefore, we decided that the Plan does not have to pay for the PrismRA testing provided on March 1, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the chronic care management evaluation (99490) provided 
on May 31, 2022, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for the evaluation and management service. You say that this procedure was done 
for your health. The Plan denied your request. The Plan says prior authorization was not obtained. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The provider in this case is not a network provider with the Plan. The Plan did not pre-approve the service 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 the chronic care management evaluation (99490) provided on May 31, 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 nursing facility services provided on June 07, 2022, by an 
out-of-network (OON) provider. 
 
 
 
 
 
 You asked the Plan to pay for nursing facility services. You say that you are requesting reconsideration. The 
Plan denied your request. The Plan says generally speaking, the enrollee must use network providers to receive 
covered care. However, if the enrollee needs medical care that Medicare requires our plan to cover and the 
providers in our network cannot provide this care, the enrollee can get this care from an out-of-network 
provider. In this situation, the enrollee will pay the same as they would pay if they got the care from a network 
provider. We encourage the enrollee to work through their primary care provider (PCP) or network specialist 
when making requests for out-of-network 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 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 nursing facility services provided on June 07, 
2022, by an out-of-network (OON) provider.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Prolia. 
 
You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied 
your request. The Plan says the services are not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for FDA-
approved drugs if they are medically accepted as safe and effective or appropriate for the particular use.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve these services. Our reviewer says that 
the services are not medically necessary. Our physician reviewer found the enrollee has rheumatoid arthritis 
and osteopenia documented by a bone density scan in September of 2022. The records do not support a 
diagnosis of osteoporosis. The Food and Drug Administration (FDA) has not stated that the requested drug is 
indicated for the enrollee's condition and the Medicare approved drug compendia do not contain a supportive 
citation for the use of the requested drug in the enrollee's clinical situation. Prolia is not safe and effective and 
reasonable and medically 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 these services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve Prolia.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99497 billed for date of service May 9, 2022. 
 
You asked the Plan to pay for procedure code 99497. You say that this service was medically necessary. The 
Plan denied your request. The Plan says payment for code 99497 is bundled into payment for code 99223. 
 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 99497 
is a column II code to column I code 99223. 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 99497 billed for date of service May 9, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to issue payment for the foot orthotics (L3010) purchased on May 3, 
2022 and May 19, 2022. 
 
You asked the Plan to issue payment for these items. You say that you are requesting a reconsideration of the 
Plan's denial for payment. The Plan denied your request. The Plan says these items are not payable as they were 
rendered by a provider who is not certified by Medicare. 
 
The Plan must follow Medicare rules. The rules say that Medicare payment cannot be made to a provider that is 
not enrolled in the Medicare program. 
 
A review of the file and Medicare records indicates that the provider at issue is not enrolled in the Medicare 
program. Therefore, we decided that the Plan does not have to issue payment for the foot orthotics (L3010) 
purchased on May 3, 2022 and May 19, 2022.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Testopel (S0189). 
 
You asked the Plan to pre-approve Testopel. You say that Testopel is medically necessary. The Plan denied 
your request. The Plan says a trial of topical and injectable generic testosterone is required before Testopel can 
be considered. 
 
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 Testopel. Our reviewer says that 
Testopel is not medically necessary. Our physician reviewer found the records show no trial of the plan 
preferred drugs, or any reason they would be unsafe or ineffective for this enrollee. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Testopel have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Testopel (S0189).
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99285 provided on June 19, 2022. 
 
You asked the Plan to pay for procedure code 99285. 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 must report services correctly. 
Providers must report services with the appropriate CPT code. In this case, we have confirmed that code 99285 
is a column II code to column I code 99291 with a modifier indicator of 0. The column II code is therefore not 
payable. 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 99285 provided on June 19, 2022.
Appeal type: Hospice
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the subsequent nursing facility care (99308) provided on 
November 2, 2021. 
 
You asked the Plan to pay for the nursing facility care. You say that the service should be covered. 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 subsequent nursing facility care (99308) provided on 
November 2, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for injections on February 11, 2022. 
 
You asked the Plan to waive the copayment for injections. You say that you want to appeal the amount being 
charged. 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 $150 
copayment per visit to outpatient hospital facility. Covered services include, but are not limited to services in 
an emergency department or outpatient clinic, such as observation services or outpatient surgery.  
 
You have been asked to pay a $150 copayment for injections. This item/service falls within the Outpatient 
hospital services 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 injections on 
February 11, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services (81404, 81405, 81406, 81479) provided on April 
12, 2021. 
 
You asked the Plan to pay for the lab services. You say that this service was medically necessary. The Plan 
denied your request. The Plan says coverage criteria has not been met. 
 
The Plan must follow Medicare rules. Medicare rules say that only the following codes should be billed for 
Cardiovascular Disease Screening: 80061 (Lipid Panel), 82465 (Cholesterol, serum, or whole blood, total), 
83718 (Lipoprotein, direct measurement; high-density cholesterol), & 84478 (Triglycerides).  
 
We looked at the file and Medicare rules. The codes billed are not covered when billed for Cardiovascular 
Disease Screening. Based on this information, we decided that Medicare rules for coverage of the lab services 
have not been met. Therefore, we decided that the Plan does not have to pay for lab services (81404, 81405, 
81406, 81479) provided on April 12, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for nursing facility visit provided on July 11, 2022, by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for nursing facility visit. You say that you are appealing the claim payment denial. 
The Plan denied your request. The Plan says the services were provided out-of-network and were not approved 
in advanced. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
  The requested provider in this case is not a network provider with the Plan. The Plan had network providers 
available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the 
item/service at issue. We found no exception that would require the Plan to pay for these items/services. 
Therefore, we decided that the Plan does not have to pay for nursing facility visit provided on July 11, 2022, by 
an out-of-network (OON) provider.