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

 
We decided that the Plan does not have to pay for the subsequent nursing facility care, per day (99308) 
rendered by the out of network (OON) provider on March 18, 2020. 
 
You asked the Plan to pay for this service. You say that you are requesting a reconsideration of the Plan's 
denial for payment. The Plan denied your request. The Plan says the service was rendered by an out of network 
provider, without prior authorization. 
 
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 has network providers available 
who can provide the service at issue in this appeal. The Plan did not pre-approve the 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 subsequent nursing facility care, per day (99308) rendered by the out of network (OON) 
provider on March 18, 2020.
Appeal type: Inpatient Hospital
Decision: Favorable

We decided that the Plan has to pay forinpatient hospital services provided on April 8, 2020, through April 13, 2020.You asked the Plan to pay forthe inpatient hospital services. You say that you would like reconsideration based on the records submitted.The Plan denied your request. The Plan says that the submitted claim includes blank present on admission (POA) for diagnosis codes that are not on the POA exempt code list.The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly.We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the inpatient hospital services havebeen met. Specifically, the claim submitted by the provider includes POA codes for each diagnosis code.Therefore, we decided that the Plan has to pay forinpatient hospital services provided on April 8, 2020, through April 13, 2020.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: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for cataract surgery (66984) and a goniotomy (65820) provided 
on January 21, 2020. 
 
You asked the Plan to pay for cataract surgery and a goniotomy. You say that you were told the enrollee had 
out-of-network benefits. The Plan denied your request. The Plan says services must be provided by providers 
that are enrolled in Medicare. 
 
The Plan must follow Medicare rules. Medicare rules say that no provider or supplier shall receive payment for 
services furnished to a Medicare beneficiary unless the provider or supplier is enrolled in the Medicare 
program. 
 
We looked at the file and Medicare rules. The provider listed on the claim is not shown to be enrolled in the 
Medicare program. Based on this information, we decided that Medicare rules for coverage of cataract surgery 
have not been met. Therefore, we decided that the Plan does not have to pay for cataract surgery (66984) and a 
goniotomy (65820) provided on January 21, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to reimburse you for the periodontal maintenance (D4910) provided on 
January 16, 2020. 
 
You asked the Plan to reimburse you for the dental service. You say that you were never told that the dentist 
did not accept Medicare this year. You say that you were reimbursed for services that you received last year. 
You also say that had you been told this, you would have gone elsewhere. The Plan denied your request. The 
Plan says you are responsible for services provided by privately contracted providers. The Plan also says they 
will not reimburse for charges incurred by providers that have 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 service at issue in this appeal were provided in a non-urgent, non-emergent situation by the provider. This 
provider has opted out of the Medicare program. Therefore, we decided that the Plan does not have to 
reimburse you for the periodontal maintenance (D4910) provided on January 16, 2020.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for the ambulance services provided by you on March 19, 2020. 
 
You asked the Plan to pay for the ambulance services. You say that you were following the COVID executive 
order for treatment in place. The Plan denied your request. The Plan says these services are not a covered 
benefit. 
 
The Plan must follow Medicare rules. The rules say that Medicare does not pay for ambulance services when 
there is no transport.  
 
The ambulance company did not provide transport services on March 19, 2020. The ambulance benefit is a 
transportation benefit. When there is no transport, neither Medicare nor the Plan pays for the services provided. 
Therefore, we decided that the Plan does not have to pay for the ambulance services provided by you on March 
19, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an orthosis (L0650) provided April 7, 2020. 
 
You asked the Plan to pay for the orthosis. You say that the item was medically necessary. The Plan denied 
your request. The Plan says the documentation provided does not support the services billed. 
 
The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when there are both a 
physician order and proof of delivery.  
 
The record does not contain a valid proof of delivery. The delivery ticket provided is not itemized and the 
delivery date does not match the date of service. 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 an orthosis (L0650) provided April 7, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for a knee orthosis with suspension sleeve (L1851, L2397, 
L2385) provided to the enrollee on April 7, 2020. 
 
You asked the Plan to pay for the orthoses. You say that the claim should be paid. The Plan denied your 
request. The Plan says there is no itemized billing/shipping invoice to verify the services billed. 
 
The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when there are both a 
physician order and proof of delivery.  
 
The record does not contain a proof of delivery to support medical necessity for the supplies provided in this 
case. There is no itemized billing/shipping invoice to verify the services billed. 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 a knee orthosis with suspension sleeve (L1851, L2397, L2385) provided to the 
enrollee on April 7, 2020.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the psychotherapy services provided on October 21, 2019. 
 
You asked the Plan to pay for the psychotherapy services. You say that you would like the plan to reconsider 
their denial. The Plan denied your request. The Plan says the services provided must be billed to the enrollee's 
primary insurance first. 
 
The Plan must follow Medicare rules. The rules state that Medicare plans are considered secondary insurers 
when an enrollee has another type of insurance. This means that the Plan is not responsible for paying for 
services until the claim for those services has gone to the primary insurer. However, plans are still required to 
coordinate their benefits with the primary insurers. Plans can coordinate their benefits with the primary insurers 
in three ways. First, the Plan can send the bill directly to the primary insurer for payment. Second, the Plan can 
direct the provider to send the bill to the primary insurer. Third, the Plan can pay for the services and submit a 
bill for reimbursement to the primary insurer. 
 
The Plan has met its obligation with regards to coordination of benefits. Specifically, the Plan has directed you, 
the provider to send the bill to the primary insurer. As the secondary insurer, the Plan cannot be held 
responsible for the psychotherapy services until the primary insurer has denied the claim for these services. 
Therefore, we decided that the Plan does not have to pay for the psychotherapy services provided on October 
21, 2019.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for the hospital discharge day services coded 99239 provided on 
December 11, 2019. 
 
You asked the Plan to pay for the hospital discharge day services. You say that you would like the plan to 
reconsider their denial. The Plan denied your request. The Plan says the services billed are not supported by the 
documentation. 
 
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 99239 is hospital discharge day management; more than 
30 minutes. 
 
We find that CPT code 99239 is not supported in the medical record. Specifically, the documentation submitted 
indicates that 30 minutes of time was spent on discharge services. The documentation does not support that 
more than 30 minutes was provided. Based on this information, we decided that Medicare rules for coverage of 
the hospital discharge day services have not been met. Therefore, we decided that the Plan does not have to pay 
for the hospital discharge day services coded 99239 provided on December 11, 2019.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for incision and drainage of abscess (10061) provided June 6, 
2019. 
 
You asked the Plan to pay for incision and drainage of abscess. You say that the enrollee's level of service was 
appropriately billed and coded based on the services rendered including but not limited to the severity of the 
enrollee's presenting symptoms. The Plan denied your request. The Plan says there is insufficient 
documentation to corroborate the service and confirm Medicare coverage has been met. 
 
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 10061 is incision and drainage of abscess (carbuncle, 
suppurative hidradenitis, cutaneous or subcutaneous abscess, cyst, furuncle, or paronychia); simple or single 
and complex or multiple. 
 
We find that CPT code 10061 is not supported in the medical record. Specifically, the documentation submitted 
did not include documentation of incision and drainage of abscess (eg, carbuncle, suppurative hidradenitis, 
cutaneous or subcutaneous abscess, cyst, furuncle, or paronychia); complicated or multiple; therefore, the billed 
service cannot be verified. Of note, there is a more appropriate Current Procedural Terminology (CPT) code 
(10060) for the procedure performed. Based on this information, we decided that Medicare rules for coverage 
of incision and drainage of abscess have not been met. Therefore, we decided that the Plan does not have to pay 
for incision and drainage of abscess (10061) provided June 6, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the new patient office or other outpatient visit (99204) 
provided on January 31, 2020, by an out of network (OON) provider. 
 
You asked the Plan to pay for new patient office or other outpatient visit. You say that you were not aware an 
authorization was needed. The Plan denied your request. The Plan says prior authorization was not obtained by 
the facility or the provider; therefore, payment has been correctly denied. 
 
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 has network providers 
available who can provide 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 new patient office or other outpatient visit 
(99204) provided on January 31, 2020, by an out of network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay forthe home ventilator (E0466) provided on January 2, 2020.You asked the Plan to pay forthe home ventilator.You say that you would like reconsideration because the home ventilator is medically necessary.The Plan denied your request. The Plan says the documentation submitted does not include an itemized shipping/billing invoice to indicate the specific supplies or proof of delivery.The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when there are both a physician order and proof of delivery. The record does not contain a valid proof of delivery for the supplies provided in this case. Specifically, the documentation submitted does not include an itemized billing/shipping invoice to verify the supplies at issue. Additionally, the record does not include a proof of delivery for the billed date of service. 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 forthe home ventilator (E0466) provided on January 2, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the injection services coded 64495 provided on January 3, 
2020. 
 
You asked the Plan to pay for the injection services. You say that you would like the plan to reconsider their 
denial The Plan denied your request. The Plan says the services billed are not supported by the documentation. 
 
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 64495 is injection(s), diagnostic or therapeutic agent, 
paravertebral facet (zygapophyseal) joint (or nerves innervating that joint) with image guidance (fluoroscopy or 
CT), lumbar or sacral; third and any additional level(s) (List separately in addition to code for primary 
procedure). 
 
We find that CPT code 64495 is not supported in the medical record. Specifically, the operative report did not 
include documentation of a diagnostic or therapeutic agent injection(s) into a lumbar or sacral paravertebral 
facet (zygapophyseal) joint (or nerves innervating that joint) with image guidance (fluoroscopy or CT); for the 
third and any additional level(s) (List separately in addition to code for primary procedure). Based on this 
information, we decided that Medicare rules for coverage of the injection services have not been met. 
Therefore, we decided that the Plan does not have to pay for the injection services coded 64495 provided on 
January 3, 2020.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for psychiatric diagnostic evaluation with medical services 
(90792-GT-U1) provided May 7, 2020. 
 
You asked the Plan to pay for the Psychiatric diagnostic evaluation with medical services. You say that the 
records provided should support the necessity of the service in dispute. The Plan denied your request. The Plan 
says the claim was billed with an invalid or missing modifier. 
 
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, per CMS guidelines, HCPCS code 90792-GT-U1 was billed with an invalid or missing modifier.  
Clinical psychologists (CPs) and clinical social workers (CSWs) CPs and CSWs cannot bill Medicare for 
psychiatric diagnostic interview examinations with medical services or medical evaluation and management 
services. They cannot bill or get paid for Current Procedural Terminology (CPT) codes 90792, 90833, 90836 
and 90838. Change Request (CR) 10152 eliminates the requirement to use the GT modifier (via interactive 
audio and video telecommunications systems) on professional claims for telehealth services. Use of the 
telehealth Place of Service (POS) Code 02 certifies that the service meets the telehealth requirements.  Based 
on this information, we decided that Medicare rules for coverage of the Psychiatric diagnostic evaluation with 
medical services have not been met. Therefore, we decided that the Plan does not have to pay for psychiatric 
diagnostic evaluation with medical services (90792-GT-U1) provided May 7, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay forthe pain management services rendered on November 18,2019.You asked the Plan to pay forthese services. You say that you disagree with the denial.The Plan denied your request. The Plan says the services are not covered.The Plan must follow Medicare rules. Medicare rules say that claims submitted where the unit of service exceeds the MUE value for the HCPCS/CPT code will be denied.In this case, the MUE for CPT code 64635 is 1. You billed 2 units of this code, exceeding the MUE. Based on this information, we decided that Medicare rules for coverage of these services have not been met.Therefore, we decided that the Plan does not have to pay forthe pain management services rendered on November 18, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a power wheelchair. 
 
You asked the Plan to pre-approve the wheelchair. You say that this is medically necessary. The Plan denied 
your request. The Plan says there must be enough rooms in the house to use a powered wheelchair. 
 
The Plan follows Medicare rules. Medicare rules say that a PMD will not be covered if the patient does not 
have mobility deficit that impairs their participation in MRADLs, the patient?s condition can be ameliorated by 
a walker, cane or manual wheelchair, or the patient is not capable of safely operating the requested PMD.  
 
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 wheelchair. Our reviewer says that 
the requested wheelchair is not medically reasonable or necessary. Our physician reviewer found based on the 
medical records provided, there is no documentation that you have a personal mobility deficit that impairs 
participation in mobility related activities of daily living. There is no documentation that your mobility deficit 
could not be helped by the use of a walker or a cane. There is no documentation that the enrollee can safely 
operate a power mobility device. 
 
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 wheelchair have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a power wheelchair.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve 9 home health nursing visits. 
 
You asked the Plan to pre-approve the home health services. The Plan denied your request. The Plan says the 
services are not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that home health care services may be covered if it is 
medically necessary for the enrollee to receive skilled nursing or therapy. A doctor must certify the need for 
home health care services. 
 
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 home health services. Our reviewer 
says that the requested home health services are not medically necessary. Our physician reviewer found that the 
records show that skilled nursing services are not required to effectively provide treatment, care, and/or 
services in order to improve the enrollee's condition, to establish/perform a maintenance program to maintain 
the enrollee's condition and/or prevent deterioration. The enrollee has been educated on her conditions. There is 
no evidence of complex wound care, new ostomy management, or other skilled nursing needs. 
 
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 home health services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve 9 home health nursing visits.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for durable medical equipment provided by a 
participating provider on February 25, 2020. 
 
You asked the Plan to waive the coinsurance for automatic external defibrillator. You say that you don't know 
the purpose of the device. You say that the device was painful and uncomfortable. The Plan denied your 
request. The Plan says the correct coinsurance has been applied. 
 
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 durable medical equipment/in-network.  
 
You have been asked to pay a 20% coinsurance of the allowed amount for automatic external defibrillator. The 
total allowed amount is $2,800. The total amount you are being asked to pay is $560 ($2,800 x 20% = $560). 
Automatic external defibrillator falls within the durable medical equipment/in-network 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 coinsurance for durable medical equipment provided by a participating 
provider on February 25, 2020.