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

 
We decided that the Plan does not have to pay for a periodic comprehensive preventive medicine reevaluation 
and management provided on June 30, 2022, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for a periodic comprehensive preventive medicine reevaluation and management. 
You say that this provider regularly complies with all administrative requirements for payments. The Plan 
denied your request. The Plan says this provider is not a network provider with the Plan. The Plan also says 
that 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 a periodic comprehensive preventive medicine 
reevaluation and management provided on June 30, 2022, by an out-of-network (OON) provider.
Appeal type: Hospice
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ambulance transport rendered on March 3, 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 enrollee was 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 ambulance transport rendered on March 3, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the infectious agent detection by nucleic acid (DNA or 
RNA), not otherwise specified; amplified probe technique, each organism (87798) and infectious agent 
detection by nucleic acid (DNA or RNA), multiple organisms; amplified probe(s) technique (87801) provided 
April 22, 2022. 
 
You asked the Plan to pay for the laboratory services. You say that please review the attached pricer and 
reprocess your claim for an additional reimbursement accordingly. The Plan denied your request. The Plan says 
the provider has not submitted any clinical records to support the medical necessity of the service. 
 
The Plan must follow Medicare rules. Medicare rules say that the provider, supplier, or beneficiary, as 
appropriate, must furnish to the intermediary or carrier sufficient information to determine whether payment is due and the amount of payment. 
 
We looked at the file and Medicare rules. Based on this information, we decided that there is insufficient 
information in the record to determine if Medicare rules for coverage of the laboratory services have been met. 
Despite multiple outreaches by the Health Plan, this provider has not submitted any clinical records to support 
the medical necessity of the services in dispute. Therefore, we decided that the Plan does not have to pay for 
the infectious agent detection by nucleic acid (DNA or RNA), not otherwise specified; amplified probe 
technique, each organism (87798) and infectious agent detection by nucleic acid (DNA or RNA), multiple 
organisms; amplified probe(s) technique (87801) provided April 22, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for genetic testing (81455) provided on March 24, 2022. 
 
You asked the Plan to pay for the genetic testing. You say that this service was medically necessary. The Plan 
denied your request. The Plan says this service is non-covered. 
 
The Plan must follow Medicare rules. Medicare rules say that Genetic testing procedures submitted with code 
81455 are unlikely to impact therapeutic decision-making in the clinical management of the patient and will be 
denied automatically as not medically necessary. 
 
We looked at the file and Medicare rules. At the time this service was rendered, the code billed was non-
covered under Medicare rules. Based on this information, we decided that Medicare rules for coverage of the 
genetic testing have not been met. Therefore, we decided that the Plan does not have to pay for genetic testing 
(81455) provided on March 24, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services (83789) provided on May 16, 2022. 
 
You asked the Plan to pay for the lab services. You say that the lab services were 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 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 the lab services 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 lab services (83789) provided on May 16, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the heavy duty, extra wide, hospital bed, with weight 
capacity greater than 350 pounds, but less than or equal to 600 pounds (E0303). 
 
You asked the Plan to pre-approve the hospital bed. You say that you need the other bed because the one you 
have is like a twin bed and is too short for you. The bed is cutting up your feet and causes you more pain and suffering. The Plan denied your request. The Plan says the enrollee does not meet the criteria for Medicare 
coverage. 
 
The Plan must follow Medicare rules. The rules say that a heavy duty extra wide hospital bed (E0301, E0303) 
is covered if the beneficiary meets one of the criteria for a fixed height hospital bed and the beneficiary's 
weight is more than 350 pounds but does not exceed 600 pounds. 
 
We looked at the file and Medicare rules. The records show that you are 5'8 and weigh 190 pounds. You also 
received a semi-electric hospital bed on June 18, 2022 which meets your medical need. Based on this 
information, we decided that Medicare rules for coverage of the hospital bed have not been met. Therefore, we 
decided that the Plan does not have to pre-approve the heavy duty, extra wide, hospital bed, with weight 
capacity greater than 350 pounds, but less than or equal to 600 pounds (E0303).
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services. 
 
You asked the Plan to pre-approve the LTACH services. 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. 
 
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically 
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 
 
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 the LTACH services. Our reviewer says 
that the requested LTACH care is not considered medically reasonable and necessary in this case. Our 
physician reviewer found the enrollee is presently receiving appropriate services in the short-term acute care 
setting. Continued care in the short-term acute care hospital is appropriate until the enrollee is stable to transfer 
to a lower level of care such as an inpatient rehabilitation facility, a sub-acute rehabilitation facility or a skilled 
nursing facility. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve long term acute care hospital (LTACH) services.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a periodic comprehensive preventive medicine 
reevaluation and management to be provided by an out-of-network (OON) provider. 
 
You asked the Plan to pre-approve a periodic comprehensive preventive medicine reevaluation and 
management. You say that you are appealing with supporting records. The Plan denied your request. The Plan 
says you have been provided access to the same specialty providers who are 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 periodic comprehensive preventive medicine reevaluation and management to be provided by an out-of-
network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services (83789) provided on February 17, 2022. 
 
You asked the Plan to pay for the lab services. You say that the services were medically necessary. The Plan 
denied your request. The Plan says this testing is not separately payable. 
 
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 the lab services 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 lab services (83789) provided on February 17, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a telehealth visit provided on May 20, 2022, by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for a telehealth visit. You say that your facility is short staffed due to illness, which 
is why a telehealth was necessary. The Plan denied your request. The Plan says the cost applied was correct. 
You did not get pre-approval for this visit, and it was also not an emergency. 
 
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 telehealth visit provided on May 20, 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 domiciliary or rest home visit provided on June 6, 2022, by 
an out-of-network (OON) provider. 
 
You asked the Plan to pay for domiciliary or rest home 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 domiciliary or rest home visit provided on June 6, 
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 Zostar (shingles) vaccine (90750) and administration 
(90471) provided on September 17, 2020. 
 
You asked the Plan to pay for the immunization. You say that this should be paid. The Plan denied your 
request. The Plan says the claim denied correctly. 
 
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 Zostar (shingles) vaccine (90750) and 
administration (90471) provided on September 17, 2020.  
 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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99100 billed for date of service April 28, 
2022. 
 
You asked the Plan to pay for procedure code 99100. You say that the services were medically necessary. The 
Plan denied your request. The Plan says procedure code 99100 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 99100 has a status indicator of B on the Physician Fee Schedule. This means that 
procedure code 99100 is not separately payable. 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 April 28, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services provided on June 8, 2022, by an out-of-network 
(OON) provider. 
 
You asked the Plan to pay for lab services. You say that this service should be covered. The Plan denied your 
request. The Plan says the cost applied was correct. You did not obtain prior authorization as an out-of-network 
provider, and this was not an emergency. 
 
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 lab services provided on June 8, 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 95907 billed for date of service May 5, 2022. 
 
You asked the Plan to pay for procedure code 95907. You say that the services were medically necessary. The 
Plan denied your request. The Plan says payment for code 95907 is bundled into payment for code 95867. 
 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 95907 
is a column II code to column I code 95867. 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 95907 billed for date of service May 5, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services provided on April 17, 2022. 
 
You asked the Plan to pay for the lab services. You say that the services were medically necessary. 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 17, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for nursing facility visit, and services provided on April 1, 2022, 
to April 9, 2022, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for nursing facility visit and services. 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, and services provided on 
April 1, 2022, to April 9, 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 office visit provided on June 14, 2022, by an out-of-network 
(OON) provider. 
 
You asked the Plan to pay for office visit. You say that you are requesting reconsideration stating you had 
vertigo and went to the ENT. The Plan denied your request. The Plan says The enrollee must receive their care 
from a network provider (for more information about this, see Section 2 in this chapter). In most cases, care the 
enrollee receives from an out-of-network provider (a provider who is not part of our plan's network) will not be 
covered. 
 
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 office visit provided on June 14, 2022, by an out-
of-network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services provided on May 3, 2022 by an out-of-network 
(OON) provider. 
 
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 unauthorized, out-of-network services are not 
covered. 
 
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. 
 
Neither your lab nor the ordering provider in this case is a network provider with the Plan. 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 lab services provided on May 3, 
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 domiciliary services provided on April 28, 2022, by an out-
of-network (OON) provider. 
 
You asked the Plan to pay for domiciliary services. 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 domiciliary services provided on April 28, 2022, 
by an out-of-network (OON) provider.