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

 
We decided that the Plan does not have to pay for an office visit provided on May 17, 2022, by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for the office visit. You say that a referral is not needed because the visit was a 
follow-up to a hospital visit. The Plan denied your request. The Plan says the rendering provider is an OON 
provider and there was no referral from an in-network provider or an 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 an office visit provided on May 17, 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 an office visit to be provided by an OON provider. 
 
You asked the Plan to pre-approve an office visit. You say that you feel this should be covered because you 
have foot problems and you don't want to see another provider as you have been seeing this provider for years. 
The Plan denied your request. The Plan says you were given approval for six visits with your out-of-network 
provider to help you transition to an in-network provider. The podiatry services are available and can be 
received from providers in the Plan's preferred 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 
an office visit to be provided by an OON provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for nursing facility visit provided on April 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 April 11, 2022, 
by an out-of-network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve additional routine transportation trips. 
 
You asked the Plan to pre-approve additional trips. You say that you had surgery. You say that you are 
receiving post-operative care and therapy. You also say that you need transportation to get to your 
appointments. The Plan denied your request. The Plan says additional trips beyond the allowed number per 
year are not covered. 
 
Medicare does not cover transport in a vehicle that is not an ambulance. However, the Plan offers a 
transportation benefit that exceeds Medicare coverage. For that reason, the Plans coverage rules apply in this 
case. The Plan covers a maximum of 48 one-way trips per year.  
 We looked at your request, the records in the case file, and the rules. Based on this information, we decided 
that you have exhausted the Plan maximum benefit for coverage of routine transportation. Therefore, we 
decided that the Plan does not have to pre-approve additional routine transportation trips.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the routine eye exam to be provided by an out-of-
network provider.  
You asked the Plan to pre-approve the routine eye exam. You say that you have seen this provider for 30 years. 
You say you have a complicated prescription and trusts this doctor to get it correctly. The Plan denied your 
request. The Plan says the provider is out-of-network. 
 
Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine 
vision and eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in 
this case. The Plan covers these services when the routine eye exam is provided by a network provider. 
 
We looked at the file and the Plan's rules. Specifically, the provider is considered an out-of-network provider. 
Based on this information, we decided that the Plan's rules for coverage of the routine eye exam have not been 
met. Therefore, we decided that the Plan does not have to pre-approve the routine eye exam to be provided by 
an out-of-network provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the power wheelchair accessories to be provided by an 
out-of-network (OON) provider. 
 
You asked the Plan to pre-approve the power wheelchair accessories. You say that the enrollee needs the 
equipment in order for them to be independent. The Plan denied your request. The Plan says the requested 
provider is an OON provider, and there are in-network providers that were contacted that can provide the 
requested service that the enrollee needs. Therefore, the authorization for service with an OON provider has 
been denied. 
 
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 
the power wheelchair accessories 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 pre-approve video electroencephalogram (VEEG) monitoring to be 
provided by an out-of-network (OON) provider. 
 
You asked the Plan to pre-approve the VEEG monitoring. You say that you are not aware of any testing of this 
type being requested. You also say that you are going to follow up with your doctor to see if this is necessary or 
a mistake. The Plan denied your request. The Plan says there are in-network providers available. 
 
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 confirmed there are 
network providers available who can provide the 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 video electroencephalogram (VEEG) monitoring to be provided by an out-of-network (OON) 
provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a power wheelchair and accessory to be provided by an 
OON provider. 
 
You asked the Plan to pre-approve a power wheelchair and accessory. You say that the enrollee has the 
capability to operate a motorized wheelchair to allow him to perform activities of daily living on his own. The 
Plan denied your request. The Plan says there are in-network providers available for the service you have 
requested. 
 
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 power wheelchair and accessory to be provided by an OON provider.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the genetic testing provided on August 27, 2021, billed with 
codes 81408 and 81249. 
 
You asked the Plan to pay for the genetic testing billed. You say that this is medically necessary testing that 
should be reimbursed. The Plan denied your request. The Plan says a genetic testing panel should be billed with 
a single comprehensive code. 
 
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 
August 27, 2021, billed with codes 81408 and 81249.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit provided on September 30, 2021, by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for an office visit. You say that you would like to request reconsideration for 
payment. The Plan denied your request. The Plan says the provider is out-of-network, and it was determined 
these services can be received 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 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 provided on September 30, 2021, by 
an out-of-network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a portable oxygen concentrator (E1392). 
 
You asked the Plan to pre-approve a portable oxygen concentrator. You say that a portable oxygen concentrator 
was denied because you have not tried a standard oxygen gas tank. You have had the standard oxygen tank E or 
D cylinder for 2 years. The Plan denied your request. The Plan says they will not preauthorize a portable 
oxygen concentrator for you. You have refused delivery of the oxygen conserving device. You have not been 
evaluated by respiratory therapy for a portable oxygen concentrator. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
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 a portable oxygen concentrator. Our 
reviewer says that the requested items/services are not considered medically reasonable and necessary in this 
case. Our physician reviewer found a portable oxygen system is covered if you are mobile within the home and 
the qualifying blood gas study was performed while at rest (awake) or during exercise. The documentation does 
not support that a portable oxygen concentrator is medically reasonable and necessary for you in this case. 
 
 We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of a portable oxygen concentrator have not been met. Therefore, we decided that 
the Plan does not have to pre-approve a portable oxygen concentrator (E1392).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the infrared therapy (97026) provided on March 15, 2022. 
 
You asked the Plan to pay for the infrared therapy. You say that this service should be reprocessed and paid. 
The Plan denied your request. The Plan says infrared therapy is not a covered benefit. 
 
The Plan must follow Medicare rules. Medicare rules say that there is sufficient evidence to conclude the use of 
infrared therapy devices and any related accessories is not reasonable and necessary. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the infrared therapy have not been met. Therefore, we decided that the Plan does not have to pay 
for the infrared therapy (97026) provided on March 15, 2022.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve additional massage therapy visits. 
 
You asked the Plan to pre-approve additional massage therapy visits. You say that when you have had massage 
therapy you are able to have very reduced pain for as much as a week, which has been consistent throughout 
the massage treatments. You say that without the treatments the muscles in your lower body become very tight 
and tense, thus increasing the pressure on the nerves and subsequent pain. The Plan denied your request. The 
Plan says you have already received 10 massage therapy visits for 2022, and your benefit for massage therapy 
has been exhausted. 
 
We looked at the file and the Plans rules. The file shows that you have exhausted the massage therapy benefit 
for 2022. Therefore, we decided that the Plan does not have to pre-approve additional massage therapy visits.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for laboratory services (87798, 87481, 87801, 87150) provided 
on June 14, 2022 by an out-of-network (OON) provider. 
 
You asked the Plan to pay for the laboratory services. You say that the services should be covered as you 
disagree with the denial. The Plan denied your request. The Plan says the services denied correctly as they were 
non-emergent and 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 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 laboratory services (87798, 87481, 87801, 87150) 
provided on June 14, 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 an office visit provided on April 19, 2022, by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for the office visit. You say that an authorization is not required for the office visit 
code, and you would like the claim to be paid. The Plan denied your request. The Plan says the rendering 
provider is an OON provider 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 an office visit provided on April 19, 2022, by an 
out-of-network (OON) provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the subsequent nursing facility care (99233 x 2) and hospital 
discharge day management; more than 30 minutes (99239) provided from February 20, 2021, to February 22, 
2021. 
 
You asked the Plan to pay for the hospital care. You say that the claim was initially filed timely. The Plan 
denied your request. The Plan says the corrected claim was filed untimely. 
 
The Plan follows Medicare rules. The rules say that a corrected claim must be receive within one year (12 
months) from the processed date of the original claim submission. 
 
The record shows that a corrected claim for the hospital care was not filed until May 3, 2022. This means that 
more than one calendar year from the processed date of the original claim submission had passed before a 
claim was filed. Therefore, we decided that the Plan does not have to pay for the subsequent nursing facility 
care (99233 x 2) and hospital discharge day management; more than 30 minutes (99239) provided from 
February 20, 2021, to February 22, 2021.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Magnetic resonance imaging (MRI) of the knee. 
 
You asked the Plan to pre-approve an MRI of the knee. You say that the requested MRI of the knee is 
medically necessary. The Plan denied your request. The Plan says the requested MRI of the knee is not 
medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that MRIs are covered only when they are medically 
necessary.  
 
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 an MRI of the knee. Our reviewer says 
that the requested MRI of the knee is not medically necessary. Our physician reviewer found the record 
indicates that the enrollee has breast cancer metastatic to brain. The record indicates that the enrollee has had 
ongoing knee pain and had normal plain films over a year ago. The record does not indicate any further work 
up, evaluation, or conservative treatment has been performed. The record does not indicate the presence of any 
red flag symptoms. The requested service is not medically necessary and reasonable for the diagnosis and 
treatment for the enrollee's clinical condition at this time. The elements of the coverage criteria are not 
satisfied. The requested service cannot be recommended. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of an MRI of the knee have not been met. Therefore, we decided that the Plan does 
not have to pre-approve a Magnetic resonance imaging (MRI) of the knee.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a consultation with an ophthalmologist to be provided 
by an out-of-network (OON) provider. 
 
You asked the Plan to pre-approve the consultation. You say that your physician referred you to the OON 
provider to receive treatment. The Plan denied your request. The Plan says the requested provider is an OON 
provider, and there are multiple in-network providers that are available for the enrollee to see. Therefore, the 
authorization for service with the OON provider is denied. 
 
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 consultation with an ophthalmologist to be provided by an out-of-network (OON) provider.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for psychotherapy provided on June 16, 2022, by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for psychotherapy. 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. The service can be provided by an in-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 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 found a number of in -
network providers in the area. 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 psychotherapy provided on June 16, 2022, by an out-of-network (OON) provider.