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

 
We decided that the Plan does not have to pay for procedure codes 99223 and 99232 provided from January 2, 
2023, to January 3, 2023. 
 
You asked the Plan to pay for procedure codes 99223 and 99232. You say that you would like the Plan to 
reconsider their denial of payment. The Plan denied your request. The Plan says the services are not covered as 
billed. 
 The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. The rules also state that any physician seeing a 
patient registered in the emergency department may use emergency department visit codes (for services 
matching the code description). It is not required that the physician be assigned to the emergency department. 
 
We find that CPT codes 99223 and 99232 are not supported in the medical record. Specifically, the records 
show that these services were provided in the emergency department and should be billed with emergency 
department visit codes. Based on this information, we decided that Medicare rules for coverage of procedure 
codes 99223 and 99232 have not been met. Therefore, we decided that the Plan does not have to pay for 
procedure codes 99223 and 99232 provided from January 2, 2023, to January 3, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code(s) 88305 and 88312 billed for date of service 
November 22, 2022. 
 
You asked the Plan to pay for procedure code(s) 88305 and 88312. You say that you would like the Plan to 
reconsider their denial of payment. The Plan denied your request. The Plan says these codes are included in the 
facility payment and are not separately payable.  
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Technical components must be billed by the facility where the enrollee was an inpatient or outpatient and are 
not separately payable to the lab. 
 
The records indicate that the specimen was taken while the enrollee was an inpatient or outpatient. Per the 
Physician Fee Schedule, there is a Professional/Technical indicator of 1 for CPT code(s) 88305 and 88312. 
This means there is both a professional and technical component for the CPT code(s). In this case, an 
appropriate modifier to indicate the professional component has not been billed with CPT code(s) 88305 and 
88312. Based on this information, we decided that Medicare rules for coverage of procedure codes 88305 and 
88312 have not been met. Therefore, we decided that the Plan does not have to pay for procedure code(s) 
88305 and 88312 billed for date of service November 22, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the magnetic resonance imaging provided 
on January 20, 2023. 
 
You asked the Plan to waive the copayment for the magnetic resonance imaging. You say that you only 
received 1 procedure during this service. The Plan denied your request. The Plan says this cost sharing was 
charged correctly. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $150 
copayment for outpatient diagnostic tests and therapeutic services and supplies. 
 
You have been asked to pay a $150 copayment for the magnetic resonance imaging. This item/service falls 
within the outpatient diagnostic tests and therapeutic services and supplies 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. However, since the allowed amount is 
less than the standard copayment, you only owe $112.30. Therefore, we decided that the Plan does not have to 
waive the copayment for the magnetic resonance imaging provided on January 20, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for osteopathic manipulative treatment (OMT) and related 
services provided on August 23, 2022. 
 
You asked the Plan to pay for osteopathic manipulative treatment (OMT) and related services. You say that the 
services should be covered. The Plan denied your request. The Plan says that unauthorized, out-of-network care 
is 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. 
 
The provider of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. The Plan 
did not pre-approve the item(s)/service(s) at issue. We found no exception that would require the Plan to pay 
for the item(s)/service(s). Therefore, we decided that the Plan does not have to pay for osteopathic 
manipulative treatment (OMT) and related services provided on August 23, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the pulmonary rehabilitation services to be provided by 
an out-of-network (OON) provider.  
 
You asked the Plan to pre-approve the pulmonary rehabilitation services. You say that it is difficult for the 
enrollee to attend in-person programs. The Plan denied your request. The Plan says enrollees must receive their 
care from a 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 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 pulmonary rehabilitation services 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 pay for the tele-health visit provided on May 9, 2022, by an out-of-
network (OON) provider.  
 
You asked the Plan to pay for the tele-health visit. You say that this service should be covered. The Plan denied 
your request. The Plan says the tele-health visit is not covered when performed by an out-of-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 provider in this case is not a network provider with the Plan. The Plan had network providers available 
who could have provided the service 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 this service. Therefore, we decided that the Plan does not have to pay for the tele-health visit provided on May 9, 2022, by an out-of-network (OON) 
provider.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Synthroid Tab. 
 
You asked the Plan to pre-approve the medication. You say that this should be covered. 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 Synthroid Tab.   
Benefits for the medication 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 codes 95941 and 95955 for date of service 
October 14, 2020. 
 
You asked the Plan to pay for procedure codes 95941 and 95955. You say that you disagree with the Plan's 
denial. The Plan denied your request. The Plan says the services 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. 
 
We find that CPT code 95955 is not supported in the medical record. Specifically, the documentation submitted 
did not include documentation of electroencephalogram (EEG) during nonintracranial surgery. We find that 
procedure code 95941 has a Status Indicator of I on the Physician Fee Schedule. This means that procedure 
code 95941 is not valid for Medicare purposes. Based on this information, we decided that Medicare rules for 
coverage of procedure codes 95941 and 95955 have not been met. Therefore, we decided that the Plan does not 
have to pay for procedure codes 95941 and 95955 for date of service October 14, 2020.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve treatment with Ondansetron tablet. 
 You asked the Plan to pre-approve Ondansetron. You say that Ondansetron is a medical necessity for the 
enrollee. 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 requested drug is not part of a cancer regimen. The self-administered drug requested 
here is not, as prescribed, among the types which are covered by Medicare Part B. Therefore, we decided that 
the Plan does not have to pre-approve treatment with Ondansetron tablet.  
 
Benefits for Ondansetron 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 reimburse you for the office visit provided on February 23, 2023. 
 
You asked the Plan to reimburse you for the evaluation and management service. You say that this is an out-of-
network endocrinologist you see once a year. You say that you paid $200 at the time of service. You say that 
this provider has you submit to insurance. You also say that you would like to be reimbursed. The Plan denied 
your request. The Plan says the provider in this case has opted out of Medicare. The Plan also says that 
payment cannot be made for services performed by a provider that has opted out of Medicare. 
 
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 reimburse you for 
the office visit provided on February 23, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services provided on January 27, 2023. 
 
You asked the Plan to pay for lab services. You say that you cannot afford to let these claims go unpaid. The 
Plan denied your request. The Plan says that unauthorized, out-of-network care is 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. 
 
The provider of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. The Plan did not pre-approve the item(s)/service(s) at issue. We found no exception that would require the Plan to pay 
for the item(s)/service(s). Therefore, we decided that the Plan does not have to pay for lab services provided on 
January 27, 2023.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve continued skilled nursing facility (SNF) care. 
 
You asked the Plan to pre-approve continued SNF care. You say that you disagree with the denial and request 
an exception for additional days beyond the 100-day benefit. The Plan denied your request. The Plan says the 
enrollee has exhausted her 100-day benefit limit. 
 
The Plan must follow Medicare rules. The rules say that enrollees are covered for up to 100 days of skilled care 
in a SNF in each benefit period. A benefit period begins on admission to a hospital or to SNF level of care and 
ends when the enrollee has gone 60 days in a row without inpatient hospital or SNF care.  
 
The file shows that the enrollee received 100 days of SNF care during the benefit period from January 26, 
2023, through June 19, 2023. The Plan has covered 100 days of SNF care.  
 
 
 
 Although the enrollee may still need skilled care, the Plan is not required to pay for more than 100 days of SNF 
coverage during this benefit period. The enrollee will be eligible for a new benefit period when the enrollee has 
not been receiving care in a hospital or skilled care in a SNF for at least 60 days in row. Therefore, we decided 
that the Plan does not have to pre-approve continued skilled nursing facility (SNF) care.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 87481 and 87653 billed for date of service 
April 13, 2022. 
 
You asked the Plan to pay for procedure codes 87481 and 87653. You say that you have billed the services at 
issue correctly. The Plan denied your request. The Plan says payment for codes 87481 and 87653 is included in 
the payment for code 87801. 
 
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 87481 and 87653 are column II codes to column I code 87801; 
however, 87481 and 87653 were billed with a modifier.  
 
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 87481 and 87653. Our reviewer says that 
procedure codes 87481 and 87653 do not meet criteria for payment. Our reviewer found that the provider 
reported procedure code 87801, which includes multiple organisms tested, amplified probe technique. In this 
case, procedure codes 87481 and 87653 would be included in code 87801. 
 
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 87481 and 87653 have not been met. Therefore, we decided 
that the Plan does not have to pay for procedure codes 87481 and 87653 billed for date of service April 13, 
2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for inpatient hospital services provided on November 7, 2022, to 
December 2, 2022, by an out-of-network (OON) provider.  
 
You asked the Plan to pay for inpatient hospital services. You say that you went to Mexico because this 
procedure was time sensitive. The Plan denied your request. The Plan says these services could have been 
provided 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. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of inpatient hospital services 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 pay for inpatient hospital services. Therefore, we decided that the 
Plan does not have to pay for inpatient hospital services provided on November 7, 2022, to December 2, 2022, 
by an out-of-network (OON) provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that you did not get the care you needed at a previous 
facility.  The Plan denied your request. The Plan says an IRF admission is not medically necessary, and your 
needs can be met at an alternate level of care.  
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 
  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 IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found that your medical problems are stable and there are no complex nursing or 
rehabilitation needs. While the medical record supports a need for physical or occupational therapy, there is no 
documented need for intensive rehabilitation services. Medically necessary care can be provided in a different 
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 IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute IRF admission and services.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the transitional care management services, advanced care 
planning, office visit, and routine blood draw provided from May 13, 2022, to June 13, 2022, by an out-of-
network (OON) provider.  
 
You asked the Plan to pay for the physician services. You say that the out-of-network benefits were reviewed 
on the website. You say that the website indicates no action is required. You also say that the enrollee required 
the services. The Plan denied your request. The Plan says prior authorization was not obtained. 
 Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The provider in this case is not a network provider with the Plan. The Plan did not pre-approve the 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 transitional care management services, advanced care 
planning, office visit, and routine blood draw provided from May 13, 2022, to June 13, 2022, by an out-of-
network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the testing provided on September 2, 2022, billed with codes 
87799, 87798, 87482, and 87150. 
 
You asked the Plan to pay for the testing billed. You say that you disagree with the Plan's denial. The Plan 
denied your request. The Plan says panel testing should be billed using one CPT code on the claim. 
 
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 a 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 testing billed have not 
been met. Therefore, we decided that the Plan does not have to pay for the testing provided on September 2, 
2022, billed with codes 87799, 87798, 87482, and 87150.
Appeal type: DME/ Orthotics
Decision: Favorable

 
We decided that the Plan has to pre-approve a continuous glucose monitor (CGM) and related supplies. 
 
You asked the Plan to pre-approve the CGM and related supplies. You say that the enrollee is on insulin 4 
times a day and the requested CGM is medically necessary. The Plan denied your request. The Plan says that 
the Medicare criteria was not met. 
 
The Plan follows Medicare rules. The rules say that therapeutic CGMs may be considered reasonable and 
necessary for enrollees with diabetes who meet the criteria referenced in the Medicare rules section. 
 
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 CGM and related supplies. Our 
reviewer says that the criteria for coverage for the CGM was met. Our physician reviewer found that the 
enrollee uses insulin 3 to 4 times a day; therefore, meets criteria for the CGM coverage. 
 
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 CGM and related supplies have been met. Therefore, we decided that the 
Plan has to pre-approve a continuous glucose monitor (CGM) and related supplies.  
 
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.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for collection of venous blood by venipuncture provided on 
February 14, 2023. 
 
You asked the Plan to pay for collection of venous blood by venipuncture. You say that the services should be 
covered. The Plan denied your request. The Plan says that unauthorized, out-of-network care is 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.  
The provider of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. The Plan 
did not pre-approve the item(s)/service(s) at issue. We found no exception that would require the Plan to pay 
for the item(s)/service(s). Therefore, we decided that the Plan does not have to pay for collection of venous 
blood by venipuncture provided on February 14, 2023.