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

 
We decided that the Plan does not have to pay for procedure code 99100 billed for date of service August 8, 
2022. 
 
You asked the Plan to pay for procedure code 99100. You say that this should be paid for. The Plan denied 
your request. The Plan says procedure code 99100 is considered bundled and not separately payable.  
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate procedure code.  
We find that procedure code 99100 has a status indicator of B on the Physician Fee Schedule. This means that 
procedure code 99100 is not separately payable. Based on this information, we decided that Medicare rules for 
coverage of procedure code 99100 have not been met. Therefore, we decided that the Plan does not have to pay 
for procedure code 99100 billed for date of service August 8, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for chronic care management services provided on February 10, 
2023. 
 
You asked the Plan to pay for chronic care management services. You say that the services were medically 
necessary. 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 chronic care 
management services provided on February 10, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services provided on April 28, 2023. 
 
You asked the Plan to pay for lab services. You say that this 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 lab services provided on 
April 28, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a walker provided on April 19, 2023. 
 
You asked the Plan to pay for a walker. You say that the services were medically necessary. 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 walker provided on 
April 19, 2023.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a thermal mammogram provided on February 1, 2023, and 
May 10, 2023. 
 
You asked the Plan to pay for the thermal mammogram. You say that your PCP told you that you needed a 
mammogram, and you asked if the thermal was something you could get and was told yes. The Plan denied 
your request. The Plan says thermography for any indication (including breast lesions which were excluded 
from Medicare coverage on July 20, 1984) is excluded from Medicare coverage because the available evidence 
does not support this test as a useful aid in the diagnosis or treatment of illness or injury. Therefore, it is not 
considered effective. 
 The Plan must follow Medicare rules. Medicare rules say that thermography for any indication (including 
breast lesions which were excluded from Medicare coverage on July 20, 1984) is excluded from Medicare 
coverage because the available evidence does not support this test as a useful aid in the diagnosis or treatment 
of illness or injury. Therefore, it is not considered effective. 
 
We looked at the file and Medicare rules. Medicare says that thermography is excluded from Medicare 
coverage. Therefore, we decided that the Plan does not have to pay for a thermal mammogram provided on 
February 1, 2023, and May 10, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code A4223 rendered from March 8, 2023, to 
March 13, 2023. 
 
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 this code is not eligible for reimbursement. 
 
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 procedure code A4223 is not supported in the medical record. Specifically, this code has a 
Medically Unlikely Edits (MUE) value of zero. This means that there is no number of appropriate units to 
report for this code Based on this information, we decided that Medicare rules for coverage of the services have 
not been met. Therefore, we decided that the Plan does not have to pay for procedure code A4223 rendered 
from March 8, 2023, to March 13, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for subsequent hospital inpatient or observation care provided 
from November 9, 2021, to January 11, 2022. 
 
You asked the Plan to pay for subsequent hospital inpatient or observation care. The Plan denied your request. 
The Plan says the claim was beyond 12 months of the date of service and denied for timely filing submission. 
 
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 subsequent hospital inpatient or observation care was not filed until  
April 11, 2023. 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 subsequent hospital inpatient or 
observation care provided from November 9, 2021, to January 11, 2022.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve prochlorperazine. 
 
You asked the Plan to pre-approve the medication. You say that you are appealing with supporting records. 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 prochlorperazine.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for laboratory drug testing provided on March 07, 2023. 
 
You asked the Plan to pay for laboratory drug testing. You say that this was medically necessary and 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 laboratory drug testing 
provided on March 07, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services provided on February 28, 2023, by an 
out-of-network (OON) provider.  
 
You asked the Plan to pay for the laboratory services. You say that these services were medically necessary. 
The Plan denied your request. The Plan says these services are not covered when provided OON and no urgent 
or emergency situation is documented. 
 
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 February 28, 
2023, by an out-of-network (OON) provider.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to waive the cost share for home infusion therapy on August 10, 2022. 
 
You asked the Plan to waive the cost share for home infusion therapy. You say that you want to appeal the 
amount being charged. 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 20% 
coinsurance for Medicare Part B Covered Drugs at primary care provider's (PCP's) office, specialist's office and 
pharmacy for home infusion therapy. Covered services include, but are not limited to professional services, 
including nursing services, furnished in accordance with the plan of care. There is a 20% coinsurance of the 
allowed amount is $6,577.68 but the amount due is $5,830 because the out-of-pocket was met. Therefore, 
results in the total cost sharing amount of $5,830. 
 
You have been asked to pay a $5,830 cost share for home infusion therapy. This item/service falls within the 
home infusion therapy 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 cost share for home 
infusion therapy on August 10, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for arthrocentesis, injection and fluoroscopic guidance for 
needle placement provided on January 23, 2023. 
 
You asked the Plan to pay for arthrocentesis, injection and fluoroscopic guidance for needle placement. 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 arthrocentesis, injection 
and fluoroscopic guidance for needle placement provided on January 23, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 96365 and 96366 rendered on April 4, 2023. 
 
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 records do not support the services billed. 
 
The Plan must follow Medicare rules. Medicare rules say that OIVIT is not covered. 
 
The records indicate that the services at issue in this case were for the purpose of outpatient intravenous insulin 
therapy. Based on this information, we decided that Medicare rules for coverage of the services have not been 
met.  Therefore, we decided that the Plan does not have to pay for procedure codes 96365 and 96366 rendered on 
April 4, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the infusion supplies and medication (A4221, A4222, and 
J2260) provided from September 17, 2022, to September 22, 2022. 
 
You asked the Plan to pay for the infusion supplies and medication. 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. 
 
The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when there is a valid 
physician order, proof of delivery and relevant medical records which support medical necessity.  
 The record does not contain a valid proof of delivery for the supplies provided in this case. The record shows 
that the Plan made several attempts to obtain the necessary documentation without success. Therefore, we 
decided that the Plan does not have to pay for the infusion supplies and medication (A4221, A4222, and J2260) 
provided from September 17, 2022, to September 22, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit provided on May 5, 2023. 
 
You asked the Plan to pay for the office visit. You say that you had no idea the provider would be billing for an 
office visit. The Plan denied your request. The Plan says chiropractic services other than the manual 
subluxation of the spine are not covered. 
 
The Plan must follow Medicare rules. The rules say that the only chiropractic service Medicare covers is 
manual manipulation of the spine to correct a subluxation.  
 
The records show that the service at issue is not manual manipulation of the spine. Therefore, we decided that 
the Plan does not have to pay for an office visit provided on May 5, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for urgent care provided on April 07, 2023. 
 
You asked the Plan to waive the copayment for urgent care. You say that you say that the provider did nothing 
and was told there would be no charge. 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 $40 
copayment for urgently needed services. 
 
You have been asked to pay a $40 copayment for urgent care. This item/service falls within the urgently 
needed services 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 urgent care provided on 
April 07, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a maxillary complete denture (D5110) and mandibular 
complete denture (D5120). 
 
You asked the Plan to pre-approve the dental services. You say that you lost your dentures and need 
replacements. The Plan denied your request. The Plan says your benefit for the requested item or service has 
already been exhausted. 
 
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, certain limitations apply. The record 
shows your benefit for the requested item or service was exhausted on date of service June 21, 2022. Therefore, 
we decided that the Plan does not have to pre-approve a maxillary complete denture (D5110) and mandibular 
complete denture (D5120).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the care planning assessment and the nursing facility care 
provided on March 30, 2023. 
 
You asked the Plan to pay for the care planning assessment and the nursing facility care. You say that you are 
requesting reconsideration of the denied claim. 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 
assessment and the nursing facility care provided on March 30, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services (81245, 81246) provided on February 8, 2023. 
 
You asked the Plan to pay for the lab services. You say that this service was medically necessary. The Plan 
denied your request. The Plan says the codes cannot be paid 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 codes 81245, & 81246 are not supported in the medical record. Specifically, these codes 
were billed with the GZ modifier and are not payable. 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 lab services (81245, 81246) provided on February 8, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit (procedure code 99213) rendered on April 11, 
2023. 
 
You asked the Plan to pay for the visit. You say that this should be paid for. The Plan denied your request. The 
Plan says Current Procedural Terminology (CPT) code 99213-AM (1 Unit) remains 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 99213 is "Office or other outpatient visit for the 
evaluation and management of an established patient, which requires a medically appropriate history and/or 
examination and low level of medical decision making. When using time for code selection, 20-29 minutes of 
total time is spent on the date of the encounter." 
 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 the visit. Our reviewer says that the services at issue in this 
case were not supported by the medical records. Our reviewer found that the records do not support that there 
was a medically appropriate history or exam. The records do not show that 20-29 minutes of total time were 
spent on this encounter. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the visit have not been met. Therefore, we decided that the Plan does not have 
to pay for an office visit (procedure code 99213) rendered on April 11, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the care planning assessment provided on March 22, 2023. 
 
You asked the Plan to pay for the care planning assessment. You say that you are requesting reconsideration of 
the denied claim. 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 
assessment provided on March 22, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit provided on February 09, 2023. 
 
You asked the Plan to pay for an office visit. 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 an office visit provided 
on February 09, 2023.