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

 
We decided that the Plan does not have to pay for the office visit and x-ray provided on May 23, 2023, by an 
OON provider.  
 
You asked the Plan to pay for the office visit and x-ray. You say that the services do not require authorization. 
The Plan denied your request. The Plan says the services were not authorized.  
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 Plan contract says the enrollees POS benefit only applies to 
covered routine dental services. 
 
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 office visit and x-ray provided on May 23, 
2023, by an OON provider.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to reduce the copayment for an outpatient observation stay provided on 
April 25, 2023. 
 
You asked the Plan to reduce the copayment for an outpatient observation stay. You say that you should not be 
responsible for an observation copayment because you never left the emergency room. 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 $300 
copayment for outpatient hospital observation. 
 
You have been asked to pay a $300 copayment for an outpatient observation stay. This item/service falls within 
the outpatient hospital observation 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 reduce the copayment for 
an outpatient observation stay provided on April 25, 2023.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the inpatient hospital stay provided from 
March 30, 2023, to April 3, 2023. 
 
You asked the Plan to waive the copayment for the inpatient hospital stay. You say that you did not have a 
choice in which surgeon the facility used, and you did not know they were out-of-network. 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 per day for days 1-6 of each inpatient hospital stay. Your contract with the Plan also says that you 
then pay a $0 copayment for days 7-90 of each inpatient hospital stay. 
 
The records show the proper in-network copayment was applied. You have been asked to pay a $150 
copayment per day for days 1-4 of the inpatient hospital stay. This item/service falls within the inpatient 
hospital care benefit category. You have not been asked to pay after day four or for the day you were 
discharged. You have been asked to pay a total of $600 for the inpatient hospital stay ($150 copayment per day 
x 4 days = $600). 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 the inpatient hospital stay 
provided from March 30, 2023, to April 3, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the care planning provided on April 14, 2023. 
 
You asked the Plan to pay for the care planning. You say that the enrollee was residing in an assisted living 
facility when services were provided. 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 the care planning 
provided on April 14, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a facility visit provided on April 24, 2023. 
 
You asked the Plan to pay for a facility visit. You say that this patient is in a facility, and you depend upon the 
facility staff for any verification or prior authorization. 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 a facility visit provided 
on April 24, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab testing provided on April 13, 2023. 
 
You asked the Plan to pay for lab testing. You say that you are requesting reconsideration stating patient is in 
nursing facility and does not have the option on what lab service to use. 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 testing provided on 
April 13, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the genicular nerve block. 
 
You asked the Plan to pre-approve the genicular nerve block. You say that You say that the genicular nerve 
block is a medically necessary procedure for the enrollee. The Plan denied your request. The Plan says the 
genicular nerve block is not medically necessary.  
 
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 the genicular nerve block. Our reviewer 
says that the genicular nerve block is not medically necessary. Our physician reviewer found that genicular 
nerve blocks and genicular nerve ablations are considered investigational and not medically necessary for the 
treatment of chronic knee pain. 
 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 genicular nerve block have not been met. Therefore, we decided that the 
Plan does not have to pre-approve the genicular nerve block.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for subsequent nursing facility care provided on August 26, 
2022. 
 
You asked the Plan to pay for subsequent nursing facility care. You say that this service is supported in the 
records. 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 subsequent nursing 
facility care provided on August 26, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 81301 and 81194 billed for date of service 
December 9, 2022. 
 
You asked the Plan to pay for procedure codes 81301 and 81194. 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 for separate billing or payment. 
 
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 81301 and 81194 is a column II code to column I code 81455; 
however, 81301 and 81194 was 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 81301 and 81194. Our reviewer says that 
these codes are not supported for separate billing or payment. Our reviewer found the laboratory report does 
not include documentation to support that these were unusual non-overlapping services; therefore, there is no 
supported rationale for separately billing these codes with the XU modifier. 
 
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 81301 and 81194 have not been met. Therefore, we decided 
that the Plan does not have to pay for procedure codes 81301 and 81194 billed for date of service December 9, 
2022.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the skilled nursing facility care provided 
from April 1, 2023, to April 17, 2023. 
 
You asked the Plan to waive the copayment for the skilled nursing facility care. You say that you cannot afford 
the copayment. 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 pay a $0 
copayment per day, for days 1-20, and a $196 copayment per day, for days 21-100, for skilled nursing facility 
care. 
 You have been asked to pay a $2940 copayment for the skilled nursing facility care ($196 copayment x 15 days 
= $2940). This item/service falls within the skilled nursing facility (SNF) care 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 the skilled nursing facility care provided from April 1, 2023, to April 
17, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an addition to lower limb prosthesis, vacuum pump, 
residual limb volume management and moisture evacuation system (L5781). 
 
You asked the Plan to pre-approve an addition to lower limb prosthesis. You say that you disagree with the 
denial. The Plan denied your request. The Plan says the requested vacuum socket is experimental and cannot be 
approved. The notes do not show why the upgraded pylon is medically needed. 
 
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 an addition to lower limb prosthesis. 
Our reviewer says that the requested items/services are not considered medically reasonable and necessary in 
this case. Our physician reviewer found the use of the requested L5781 vacuum assisted suspension system for 
residual limb volume management and moisture evacuation systems among lower extremity amputees is 
unproven and not medically necessary due to insufficient evidence of safety and/or efficacy. The physician 
documentation does not support the need for the elevated vacuum suspension system. 
 
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 addition to lower limb prosthesis have not been met. Therefore, we decided 
that the Plan does not have to pre-approve an addition to lower limb prosthesis, vacuum pump, residual limb 
volume management and moisture evacuation system (L5781).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the additional facet joint injection. 
 
You asked the Plan to pre-approve the additional facet joint injection. You say that this is medically necessary. 
The Plan denied your request. The Plan says this is not 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 facet joint injections. Our reviewer says 
that the service is not medically necessary. Our physician reviewer found the LCD has a utilization limit of 2 
levels. This request represents a third level which is beyond the utilization limit. There is no specific reason 
given to necessitate exceeding the limit. Therefore, the request for a third level is considered not medically 
reasonable and necessary. 
 
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 additional facet joint injection been met. Therefore, we decided that the Plan 
does not have to pre-approve the additional facet joint injection.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the office visit provided on April 25, 2023, by an OON 
provider.  
 
You asked the Plan to pay for the office visit. You say that the enrollee moved and did not notify their primary 
care provider. The Plan denied your request. The Plan says the services were not authorized. 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 Plan contract says the enrollees POS benefit only applies to 
covered routine dental services. 
 
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 office visit provided on April 25, 2023, by an 
OON provider.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve kyphoplasty (22514, 22515). 
 
You asked the Plan to pre-approve kyphoplasty. You say that this is medically necessary. The Plan denied your 
request. The Plan says this is not medically necessary because the records show the enrollee does not have 
osteoporosis and subsequently the enrollee does not have an osteoporotic vertebral compression fracture. 
 
The Plan follows Medicare rules. Medicare rules say that kyphoplasty can be covered when specific criteria are 
met. 
 
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 kyphoplasty. Our reviewer says that the 
enrollee does not meet criteria for coverage. Our physician reviewer found there is no documentation of a trial 
of bracing for fracture 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 kyphoplasty have not been met. Therefore, we decided that the Plan does not 
have to pre-approve kyphoplasty (22514, 22515).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for principal care management services provided on June 12, 
2023. 
 
You asked the Plan to pay for principal care management 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 principal care 
management services provided on June 12, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for codes G0481 and 80307 for date of service January 12, 2023. 
 
You asked the Plan to pay for codes G0481 and 80307. You say that you disagree with the Plan's denial. The 
Plan denied your request. The Plan says the services billed 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. 
 
We find that CPT codes G0481 and 80307 are not supported in the medical record. Specifically, the submitted 
medical records included lab results/findings; however, the records do not indicate a clear provider intent to 
order the specific tests requested. Based on this information, we decided that Medicare rules for coverage of 
codes G0481 and 80307 have not been met. Therefore, we decided that the Plan does not have to pay for codes 
G0481 and 80307 for date of service January 12, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an oxygen accessory, battery pack/cartridge for portable 
concentrator (E1356). 
 
You asked the Plan to pre-approve an oxygen accessory. You say that you need this item because your oxygen 
keeps dropping. The Plan denied your request. The Plan says Medicare does not provide coverage for portable 
oxygen concentrator (POC) batteries as the item itself. 
 
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 an oxygen accessory have not been met. Specifically, Medicare does not provide coverage for POC 
batteries, including an extra set of batteries or a double battery. Therefore, we decided that the Plan does not 
have to pre-approve an oxygen accessory, battery pack/cartridge for portable concentrator (E1356).
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 99285, 25600, and 93010 billed for date of 
service March 23, 2023. 
 
You asked the Plan to pay for procedure codes 99285, 25600, and 93010. You say that you disagree with the 
Plan's denial. The Plan denied your request. The Plan says payment for code 93010 is bundled into payment for 
code 25600. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. Medicare rules also say that many services 
within the postoperative period are considered to be included within payment for the global surgical procedure. 
Two exceptions to this are EM services unrelated to the surgical procedure, which should be billed with 
modifier -24, and unrelated surgical procedures, which should be billed with modifier -79. 
 
Code 99285 is included in the 90-day global period of code 25600. The medical records submitted do not 
indicate that the decision to perform surgery and/or perform a 90-day global service was made on the billed 
date of service; therefore, the use of -57 modifier is not supported. This means this cannot be separately 
reimbursed as billed. The submitted medical records do not support fracture care was performed. The 
documentation indicates that the Emergency Room physician diagnosed a closed fracture of distal end of left 
radius, with application of splint and referral to ortho. There is no mention of reduction, repositioning or 
realignment being performed; therefore, code 25600 is not supported. In this case, we have confirmed that code 
93010 is a column II code to column I code 25600. While code 93010 was billed with modifier -59, the 
medical records provided do not show that the service billed with the -59 modifier is a distinct procedural 
service. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we decided that 
the Plan does not have to pay for procedure codes 99285, 25600, and 93010 billed for date of service March 23, 
2023.