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

 
We decided that the Plan does not have to pay for the remote monitoring feature (A9279), provided on 
November 5, 2021. 
 
You asked the Plan to pay for the remote monitoring feature. You say that the service should be covered. The 
Plan denied your request. The Plan says this is not a covered service. 
 
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. Based on this information, we decided that Medicare rules for 
coverage of the remote monitoring feature have not been met. Therefore, we decided that the Plan does not 
have to pay for the remote monitoring feature (A9279), provided on November 5, 2021.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the nursing facility services (99315, 99309) provided from 
December 8, 2020, to December 11, 2020. 
 
You asked the Plan to pay for nursing facility services. You say that these services were medically necessary 
and were pre-approved for coverage by the Plan. The Plan denied your request. The Plan says these services 
were billed with an incorrect Place of Service (POS) code. This claim needs to be corrected in order to be paid. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. The 
rules say that a physician/practitioner/supplier furnishing services to a patient who is a registered inpatient, 
shall, at a minimum, report the inpatient hospital POS code 21 irrespective of the setting where the patient 
actually receives the face-to-face encounter. In this case, skilled nursing facility services were billed with POS code 31. However, the documentation 
indicates that you were inpatient hospital status from December 7, 2020, to December 23, 2020. This means 
that these services should be billed with POS code 21. The provider needs to submit a corrected claim in order 
for payment to be considered. Based on this information, we decided that Medicare rules for coverage of 
nursing facility services have not been met. Therefore, we decided that the Plan does not have to pay for the 
nursing facility services (99315, 99309) provided from December 8, 2020, to December 11, 2020.
Appeal type: Hospice
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the coronavirus testing (U0004, U0005) provided on 
September 2, 2021. 
 
You asked the Plan to pay for the laboratory services. You say that the enrollee was not enrolled in hospice on 
the date of service in this case. 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 coronavirus testing (U0004, U0005) provided on 
September 2, 2021.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the outpatient physical therapy (PT), occupational therapy 
(OT), and speech therapy (ST) services provided from July 1, 2020, to July 31, 2020. 
 
You asked the Plan to pay for the PT, OT, and ST services. You say that the services were necessary. The Plan 
denied your request. The Plan says the claim was processed correctly. 
 
The Plan follows Medicare rules. The rules say that claims for services furnished on or after January 1, 2010, 
must be filed no later than one calendar year after the date of service. 
 
The record shows that a claim for the PT, OT, and ST services was not filed until November 10, 2021. This 
means that more than one calendar year from the date of service had passed before a claim was filed. Therefore, we decided that the Plan does not have to pay for the outpatient physical therapy (PT), occupational 
therapy (OT), and speech therapy (ST) services provided from July 1, 2020, to July 31, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the lumbar injections provided on November 6, 2021, by an 
out-of-network (OON) provider. 
 
You asked the Plan to pay for the OON services. You say that the services were authorized. The Plan denied 
your request. The Plan says the services were not urgent, emergent, or 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 provider in this case is not a network provider with the Plan. The Plan had network providers available 
who could have provided the services at issue in this appeal. The Plan did not pre-approve the services 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 lumbar injections provided on November 6, 2021, by an out-of-network 
(OON) provider.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the drug testing rendered on September 13, 2021. 
 
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says the services are not covered. 
 
The Plan must follow Medicare rules. Medicare rules say that definitive drug testing is covered when specific 
criteria are met. 
 
 We looked at the file and Medicare rules. The file contains no documentation to support that the criteria for 
coverage of definitive drug testing were met. 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 pay for the 
drug testing rendered on September 13, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the lab services provided on September 24, 2020. 
 
You asked the Plan to pay for the lab services. The Plan denied your request. The Plan says the services were 
billed with the incorrect place of service. 
 
The Plan must follow Medicare rules. Medicare rules say that the POS code to be used by the physician or 
other supplier will be assigned as the same setting in which the beneficiary received the face-to-face service.  
 
We looked at the file and Medicare rules. The documentation shows that the services in question were billed with POS code 81. However, the records indicate that the specimen was collected in an office setting, which 
would be indicated by POS code 11. This means that the claim was billed with the incorrect POS code. 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 the lab services provided on September 24, 2020.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for Guardant360 testing (81479) provided on June 2, 2021. 
 
You asked the Plan to pay for Guardant360 testing. You say that this was billed correctly. The Plan denied your 
request. The Plan says this was not billed with the correct place of service. 
 
 
 The Plan must follow Medicare rules. Medicare rules say that 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 Guardant360 testing 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 Guardant360 testing (81479) provided on June 2, 2021.
Appeal type: Hospice
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the outpatient office visit (99214) provided on March 22, 
2021. 
 
You asked the Plan to pay for the outpatient visit. 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 outpatient office visit (99214) provided on March 22, 
2021.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the outpatient physical therapy (PT), occupational therapy 
(OT), and speech therapy (ST) services provided from September 2, 2020, to September 30, 2020. 
 
You asked the Plan to pay for the PT, OT, and ST services. You say that the services were necessary. The Plan 
denied your request. The Plan says the claim was processed correctly. 
 
The Plan follows Medicare rules. The rules say that claims for services furnished on or after January 1, 2010, 
must be filed no later than one calendar year after the date of service. 
 
The record shows that a claim for the PT, OT, and ST services was not filed until November 10, 2021. This 
means that more than one calendar year from the date of service had passed before a claim was filed. Therefore, we decided that the Plan does not have to pay for the outpatient physical therapy (PT), occupational 
therapy (OT), and speech therapy (ST) services provided from September 2, 2020, to September 30, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the office visit provided on March 2, 2021, by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for the office visit. You say that you do not understand why you received the denial. 
You say your other out-of-network claims were overturned, and you thought this claim was also taken care of. 
The Plan denied your request. The Plan says no prior authorization was 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 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 office visit provided on March 2, 2021, by an 
out-of-network (OON) provider.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the sleep study (CPT code 95807) to be provided at an 
out-of-network provider. 
 
You asked the Plan to pre-approve the sleep study. You say that the service is necessary. The Plan denied your 
request. The Plan says the provider did not send records that show the enrollee has a medical need to get care 
outside of the enrollee's 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 provider at issue in this case is not a network provider with the Plan. 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 sleep study. Our physician reviewer found the out-of-network study was 
requested because there were no nearby sleep centers. But there are two (2) in-network sleep labs within 
acceptable distances. The denial of the out-of-network sleep study is therefore upheld. 
 
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 sleep study have not been met.  
 
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 the sleep study. Therefore, we decided that the Plan 
does not have to pre-approve the sleep study (CPT code 95807) to be provided at an out-of-network provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the comprehensive oral evaluation - new or established 
patient (D0150) and intraoral - complete series of radiographic images (D0210) provided May 26, 2021. 
 
You asked the Plan to pay for the comprehensive oral exam and complete series of x-rays. You say that no one 
mentioned that you would have to pay for the services. The Plan denied your request. The Plan says you have 
exceeded the frequency limit for these services. 
 
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. The Plan covers the 
comprehensive oral exam and complete series of x-rays once every three plan years.  
 
We looked at the file and Medicare rules. The Plan provided documentation showing that a comprehensive oral 
exam and complete series of x-rays were previously covered on October 5, 2020. Based on this information, we decided that the Plan's rules for coverage of the comprehensive oral exam and complete series of x-rays have 
not been met. Therefore, we decided that the Plan does not have to pay for the comprehensive oral evaluation - 
new or established patient (D0150) and intraoral - complete series of radiographic images (D0210) provided 
May 26, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the office visit (99202) provided on March 10, 2021. 
 You asked the Plan to pay for the office visit. You say that you would like reconsideration based on the records 
submitted. The Plan denied your request. The Plan says there is not an established relationship between the 
enrollee and ordering provider. 
 
The Plan must follow Medicare rules. Medicare rules say that unless provided otherwise, other services 
included on the Medicare telehealth services list must be furnished using, at a minimum, audio and video 
equipment permitting two-way, real-time interactive communication between the patient and distant site 
physician or practitioner. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the office visit have not been met. Specifically, the documentation does not clearly indicate that the 
service was furnished using audio and video equipment permitting two-way, real-time interactive 
communication between the patient and distant site physician or practitioner. CPT code 99202 is not included 
on the list of codes which are appropriate for audio-only telehealth services. The documentation does not 
clearly show if this service was furnished using audio-only or audio-video communication. Therefore, we 
decided that the Plan does not have to pay for the office visit (99202) provided on March 10, 2021.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve SNF care. 
 
You asked the Plan to pre-approve SNF care. You say that the enrollee needs care to avoid continued cost for 
hospital, continued exposure to facility and infections. The Plan denied your request. The Plan says the stay is 
not medically necessary based on SNF criteria. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors 
listed in the Medicare rules section are met. Custodial care is 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 SNF care. Our reviewer says that daily 
skilled services are not necessary. Our physician reviewer found the enrollee does not qualify for SNF 
coverage. The enrollee does not have documented skilled nursing needs. The enrollee does not have 
documented skilled therapy needs. Daily skilled services are not shown to be required to establish a 
maintenance program or to prevent deterioration of the enrollees condition. The enrollees care needs, 
custodial and intermittent, can, as a practical matter, be provided at a lower level of care. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of SNF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve SNF care.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an esophagogastroduodenoscopy provided 
on October 25, 2021. 
 
You asked the Plan to waive the copayment for an esophagogastroduodenoscopy. You say that you are being 
charged a copayment of $350 on a total allowed amount of $794.98 for operating room services. You also say 
that you understood this charge should have been paid in full by your insurance. The Plan denied your request. 
The Plan says you have been charged the correct cost sharing amount. 
 
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 $350 
copayment for surgery at an outpatient hospital.  
 
 An esophagogastroduodenoscopy is considered a surgical service. You have been asked to pay a $350 
copayment for an esophagogastroduodenoscopy. An esophagogastroduodenoscopy falls within the Hospital 
Outpatient Facilities and Ambulatory Surgical Centers 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 an esophagogastroduodenoscopy provided on October 25, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for wound care provided on July 23, 2021, to July 30, 2021, by 
an out-of-network (OON) provider. 
 
You asked the Plan to pay for the wound care. You say that due to the place of service setting, it is not always 
possible to obtain an authorization.  You say the services were medically necessary. The Plan denied your 
request. The Plan says no prior authorization was 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 did not pre-approve the 
item/service at issue. We found no exception that would require the Plan to pay for these items/services. The 
records provided for review do not show that the services at issue were urgent or emergent. Therefore, we 
decided that the Plan does not have to pay for wound care provided on July 23, 2021, to July 30, 2021, by an 
out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes S1015 and S8301 billed for date of service 
September 13, 2021. 
 
You asked the Plan to pay for procedure codes S1015 and S8301. You say that these services were provided at 
your own cost, so these codes should be paid. The Plan denied your request. The Plan says these are not 
payable codes. 
 
The Plan must follow Medicare rules. Medicare rules say that procedure codes that have a status indicator of 'I' 
in the Medicare Physician Fee Schedule Database are not valid for Medicare purposes. Medicare uses another 
code for reporting of and payment for these services.  
 
 
 
 Both codes S1015 and S8301 have a status indicator of 'I' in the Medicare Physician Fee Schedule Database. 
Therefore, we decided that the Plan does not have to pay for procedure codes S1015 and S8301 billed for date 
of service September 13, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a therapeutic continuous glucose monitor (CGM). 
 
You asked the Plan to pre-approve a therapeutic CGM. You say that this device is medically reasonable and 
necessary. The Plan denied your request. The Plan says the criteria for a CGM have not been met. 
 
The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are considered medically 
reasonable and necessary for enrollees with diabetes who use insulin with at least three daily administrations, 
require frequent self-adjustment of insulin dosage based on the blood glucose testing results and have had an 
in-person visit with their treating physician to assess adherence to their CGM regimen and diabetes treatment 
plan. 
 
We looked at the file and Medicare rules. The documentation indicates that the enrollee does not use insulin 
with at least three daily injections. Based on this information, we decided that Medicare rules for coverage of a therapeutic CGM have not been met. Therefore, we decided that the Plan does not have to pre-approve a 
therapeutic continuous glucose monitor (CGM).
Appeal type: Hospice
Decision: Unfavorable

 
We decided that the Plan does not have to pay for critical care services provided to the enrollee on April 19, 
2021. 
 
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. 
The Plan says the enrollee was in a federal hospice program during the time services were rendered. 
 
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 critical care services provided to the enrollee on April 19, 
2021.