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 March 2, 2023. 
 
You asked the Plan to pay for the office visit. The Plan denied your request. The Plan says 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 Plan says that the Plan has also determined that these services are not urgent or emergent, 
nor were they 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 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 an office visit provided on March 2, 2023.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to pay for code 93005 billed for date of service March 28, 2023. 
 
You asked the Plan to pay for code 93005. You say that this is a covered service and was medically necessary. 
The Plan denied your request. The Plan says this code is not separately payable. 
 
The rules say that STV-packaged services are services for which separate payment is made only if there is no 
service with status indicator S, T, or V reported on the same claim. If a claim includes a service that is assigned 
status indicator S, T, or V reported on the same claim as the STV- packaged service, the payment for the STV-
packaged service is packaged into the payment for the service(s) with status indicator S, T, V and no separate 
payment is made for the STV-packaged service. STV-packaged services are assigned status indicator Q1. In 
this case, the code in dispute has a status indicator of QI, meaning that it is a STV-packaged service.  This 
disputed code was billed on the same claim with a code that has a status indicator of S, T, or V.  This means that the code in dispute in this appeal is not separately payable. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of code 93005 have not been met. Therefore, we decided that the Plan does not have to pay for code 
93005 billed for date of service March 28, 2023.
Appeal type: Step-Therapy
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Trelstar. 
 You asked the Plan to pre-approve the medication. You say that records have been provided to show medical 
necessity. The Plan denied your request. The Plan says the enrollee has not tried and failed preferred 
medications. 
 
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 the medication. Our reviewer says that 
the requested medication does not meet the requirements for step therapy guidelines. Our physician reviewer 
found the Plan requires a trial of Eligard and Lupron before they will approve the requested drug. In this case, 
the patient has not tried and failed the required drug(s). There is no documentation provided indicating that the 
plan's required drug(s) would likely be less effective and/or likely have adverse effects for the 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 the medication have not been met. Therefore, we decided that the Plan does not 
have to pre-approve Trelstar.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Nubeqa. 
 
You asked the Plan to pre-approve the medication. You say that this is medically necessary. The Plan denied 
your request. The Plan says the medication is not covered as a medical benefit under the Plan. 
 
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-
administered drugs. The self-administered drugs requested here are not among the types which are covered by 
Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve Nubeqa.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for codes A6209 and A9270 for date of service April 7, 2023.  

You asked the Plan to pay for codes A6209 and A9270. You say that you disagree with the Plan's denial. The 
Plan denied your request. The Plan says the codes are not payable 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. The rules also say that claim lines for code 
A6209 billed without modifiers A1-A9 will be rejected. 
 
Code A6209 was billed without A1-A9 modifiers. This means this code is not payable as billed. We find that 
CPT code A9270 is not payable as billed. Specifically, this code represents a non-covered item or service. 
Based on this information, we decided that Medicare rules for coverage of codes A6209 and A9270 have not 
been met. Therefore, we decided that the Plan does not have to pay for codes A6209 and A9270 for date of 
service April 7, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit provided by an opted-out physician on July 26, 
2022. 
 
You asked the Plan to pay for office visit. You say that your primary insurance paid a portion of the bill, now it 
is the Plan's turn to pay the balance. The Plan denied your request. The Plan says this physician has opted out 
of Medicare and is not payable. 
 
The Plan must follow Medicare rules. The rules say that no Medicare payment may be made to a beneficiary 
for items or services provided directly by a physician or practitioner who has opted out of the program except 
in cases involving emergencies or urgently needed care. 
 
The services at issue in this appeal were provided in a non-urgent, non-emergent situation by the provider who 
has opted out of the Medicare program. Therefore, we decided that the Plan does not have to pay for an office 
visit provided by an opted-out physician on July 26, 2022.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for psychotherapy provided from January 10, 2023, to 
February 14, 2023. 
 
You asked the Plan to pay for the psychotherapy. You say that you have been going to this provider for two 
years. The Plan denied your request. The Plan says this provider specialty is not Medicare-qualified mental 
health care professional. 
 
The Plan must follow Medicare rules. Medicare rules say that a Mental Health Counselor is not eligible to 
participate in the Medicare program. 
 
We looked at the file and Medicare rules. The provider at issue in this case is a Mental Health Counselor. 
Medicare says that a Mental Health Counselor is not eligible to participate in the Medicare program.  
Therefore, we decided that the Plan does not have to pay for psychotherapy provided from January 10, 2023, to 
February 14, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for 99223 and 99232 billed for dates of service January 10, 
2023, to January 17, 2023. 

You asked the Plan to pay for the billed services. The Plan denied your request. The Plan says the billed codes 
are not supported. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
In this case, the CPT Code Manual definition of code 99223 is initial hospital inpatient or observation care, per 
day, for the evaluation and management of a patient, which requires a medically appropriate history and/or 
examination and high level of medical decision making. When using total time on the date of the encounter for 
code selection, 75 minutes must be met or exceeded. 
 
The definition of code and 99232 is subsequent hospital inpatient or observation care, per day, for the 
evaluation and management of a patient, which requires a medically appropriate history and/or examination 
and moderate level of medical decision making. When using total time on the date of the encounter for code 
selection, 35 minutes must be met or exceeded. 
 
We find that CPT codes 99223 and 99232 are not supported in the medical record. The records show that the 
enrollee presented with abdominal distention. A sigmoidoscopy was provided. The records show that the 
enrollee was alert and oriented, and all other systems besides the abdomen were negative. The records do not 
show that a high level or moderate level of decision making was provided. The records do not indicate the 
amount of time spent on the enrollee for each date of service at issue. Based on this information, we decided 
that Medicare rules for coverage of the billed services have not been met. Therefore, we decided that the Plan 
does not have to pay for 99223 and 99232 billed for dates of service January 10, 2023, to January 17, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the pneumatic compression device provided on June 20, 
2023. 
 
You asked the Plan to pay for the pneumatic compression device. You say that this device was provided for use 
during the patient's surgery. The Plan denied your request. The Plan says equipment used in a facility for a 
procedure is not separately payable. 
 
The Plan must follow Medicare rules. The rules state that for equipment to be covered, it must be appropriate 
and needed for use inside the home.  
 
The item at issue in this appeal is for use outside of the home. Although this item may be helpful, neither 
Medicare nor the Plan covers equipment for use outside the home. Therefore, we decided that the Plan does not 
have to pay for the pneumatic compression device provided on June 20, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services provided on April 7, 2023, by an out-
of-network (OON) provider.  
 
You asked the Plan to pay for the laboratory services. You say that the enrollee did not choose the laboratory 
that was used. The Plan denied your request. The Plan says this service is not covered when provided OON. 
 
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 April 7, 2023, 
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 tetanus, diphtheria, and pertussis (Tdap) vaccination and 
its administration received on February 14, 2023. 
 
You asked the Plan to pay for the Tdap vaccination and administration. You say that your doctor deemed these 
vaccine boosters as necessary. The Plan denied your request. The Plan says Tdap vaccinations are not covered 
under your Part C coverage with the Plan. 
 
In the absence of injury or direct exposure to illness, Medicare does not pay for or provide the Tdap 
vaccination and administration. The Plan follows the same rules.  
 
Records do not show that you have been injured or directly exposed to any illness related to the Tdap 
vaccination and administration. Therefore, we decided that the Plan does not have to pay for the tetanus, 
diphtheria, and pertussis (Tdap) vaccination and its administration received on February 14, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an extraction and placement of intra-socket biological 
dressing (D7210, D7922) provided on February 20, 2023. 
 
You asked the Plan to pay for the dental 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 do not fall 
within your dental benefits. 
 
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. 
 
 
  Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for an 
extraction and placement of intra-socket biological dressing (D7210, D7922) provided on February 20, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 87900, 87652 and 87899 billed for date of 
service April 4, 2023. 
 
You asked the Plan to pay for procedure codes 87900, 87652 and 87899. You say that these services were 
necessary and are supported in the medical record. The Plan denied your request. The Plan says these codes are 
not supported in the records provided. 
 
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 asked our coder to carefully review the case file and apply the relevant Medicare rules to determine if the 
Plan was correct in denying the request to pay for procedure codes 87900, 87652 and 87899. Our reviewer says 
that the codes in question are not supported by the medical record. Our reviewer found that the record does not 
contain complete results that satisfy the criteria in the code descriptions. It cannot be verified that these tests 
were performed as billed. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of procedure codes 87900, 87652 and 87899 have not been met. Therefore, we 
decided that the Plan does not have to pay for procedure codes 87900, 87652 and 87899 billed for date of 
service April 4, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve office visits (99204, 99214) with a dermatologist to be 
provided by an out-of-network (OON) provider. 
 
You asked the Plan to pre-approve office visits. You say that you would like to see the requested dermatologist. 
The Plan denied your request. The Plan says you must use network providers to get health care and services 
when there are 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 network providers 
available who can provide the items/services at issue in this appeal. We found no exception that would require 
the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve 
office visits (99204, 99214) with a dermatologist 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 the urine polymerase chain reaction (PCR) panel provided on 
February 28, 2023, and billed with codes 87481, 87640, 87641, 87653, and 87798. 
 
You asked the Plan to pay for the urine PCR panel. You say that this testing was medically necessary. The Plan 
denied your request. The Plan says this testing should be billed with a single panel code. 
 
The Plan must follow Medicare rules. Medicare rules say that a panel cannot be unbundled and billed as 
individual components. 
 
We looked at the file and Medicare rules. This test was not billed with a singled panel code as required. Based 
on this information, we decided that Medicare rules for coverage of the urine PCR panel have not been met. Therefore, we decided that the Plan does not have to pay for the urine polymerase chain reaction (PCR) panel 
provided on February 28, 2023, and billed with codes 87481, 87640, 87641, 87653, and 87798.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve 10 additional physical therapy visits.   
 
You asked the Plan to pre-approve the therapy services. You say that you do not have range of motion on your 
right side which is a new discovery during treatment. You are still having pain in your hip and back and would 
like to feel better. The Plan denied your request. The Plan says 10 additional physical therapy visits are not 
medically necessary. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for medically necessary outpatient 
therapy. 
 
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 therapy services. Our reviewer says 
that skilled services are not necessary to restore or maintain function or to prevent deterioration of your 
condition. Our physician reviewer found you continue to experience hip and low back pain. However, there is 
insufficient documentation of objective progress with continued therapy, including your level of function as 
well as motor strength and range of motion. You can manage her pain and tightness with a home exercise 
program. 
 
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 therapy services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve 10 additional physical therapy visits.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for psychotherapy provided on April 4, 2023. 
 
You asked the Plan to pay for the psychotherapy. You say that the services were medically necessary. The Plan 
denied your request. The Plan says the provider must attempt to consult the attending or primary care physician 
about the services furnished and document the consent or declination date to consultations and the date of 
consultations in the patients medical record. If consultation with the attending or primary care physician is unsuccessful, document the patients medical chart with the date and manner of notification to 
the physician. There was no documented contact with the attending/primary care physician. 
 
The Plan must follow Medicare rules. Medicare rules say that the CP or LCSW must document, in the patient's 
medical record, the date the patient consented or declined consent to consultations, the date of consultation, or, 
if attempts to consult did not succeed, that date and manner of notification to the physician. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the psychotherapy have not been met. Specifically, the record does not include documentation of a 
consultation or an attempt to consult the enrollee's primary/attending physician as required by Medicare rules. 
Therefore, we decided that the Plan does not have to pay for psychotherapy provided on April 4, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for outpatient intravenous (IV) insulin therapy (OIVIT) services. 
 
You asked the Plan to pay for OIVIT. You say that you have billed the services at issue correctly. The Plan 
denied your request. The Plan says rules for payment have not been met. 
 
  The Plan must follow Medicare rules. Medicare rules say that OIVIT is not reasonable and necessary for any 
indication. Based on this information, we decided that Medicare rules for coverage of OIVIT have not been 
met. Therefore, we decided that the Plan does not have to pay for outpatient intravenous (IV) insulin therapy 
(OIVIT) services.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for medication assisted treatment, methadone provided on 
April 3, 2023. 
 
You asked the Plan to pay for medication assisted treatment, methadone. The Plan denied your request. The 
Plan says 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 Plan says that the Plan has also determined that these services 
are not urgent or emergent, nor were they 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 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 medication assisted treatment, methadone provided on  
April 3, 2023.
Appeal type: Supplemental Benefit
Decision: Favorable

 
We decided that the Plan has to pay for a crown and core buildup services for tooth #14 ((D2740, D2950) 
provided on June 27, 2023. 
 
You asked the Plan to pay for the dental services. You say that the services should be covered as you disagree 
with the denial. The Plan denied your request. The Plan says that the services denied correctly as they were not 
medically necessary, 
 
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and 
diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or 
payment. 
 
The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their 
decision to deny your request. We have yet to receive any medical records to support the Plans denial. 
Therefore, we decided that the Plan has to pay for a crown and core buildup services for tooth #14 ((D2740, 
D2950) provided on June 27, 2023.  
 
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again 
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake 
and/or send us the new information. This does not happen often. If we decide to open the case again, we will 
send you a letter.