Persius/hicric huggingface dataset:
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for radiologic examination, foot; complete, minimum of 3 views 
(CPT Code 73630) provided to the enrollee on February 1, 2019. 
 
You asked the Plan to pay for the foot x-ray. You say that the claim should be paid. The Plan denied your 
request. The Plan says the services are not supported by the records. 
 
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 73630 is not supported in the medical record. Specifically, the submitted medical 
records do not indicate that radiologic examination, foot; complete, minimum of 3 views was performed. 
Therefore, the billed service cannot be verified. It is noted that multiple attempts were made to contact the 
provider for additional information. Based on this information, we decided that Medicare rules for coverage of 
the foot x-ray have not been met. Therefore, we decided that the Plan does not have to pay for radiologic 
examination, foot; complete, minimum of 3 views (CPT Code 73630) provided to the enrollee on February 1, 
2019.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the skilled nursing services provided from February 11, 2020 
to February 17, 2020. 
 
You asked the Plan to pay for the skilled nursing services. You say that the services which the enrollee required 
and received are coverable under the Medicare Act. The Plan denied your request. The Plan says the enrollee's 
condition no longer required daily skilled services at an inpatient SNF level of care. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors 
listed above are met. Custodial care is 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 pay for the skilled nursing services. Our reviewer 
says that the enrollee did not meet the Medicare criteria for SNF care. Our physician reviewer found the 
enrollee did not have daily skilled nursing needs that required the specialized skill, knowledge, and judgment 
of a skilled professional nurse. The enrollee did not have daily skilled therapy needs that required the 
specialized skill, knowledge, and judgment of a skilled professional therapist. The enrollee did not require daily 
skilled nursing and/or skilled therapy on an inpatient basis in a SNF setting. 
 
 
 
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 skilled nursing services have not been met. Therefore, we decided that the 
Plan does not have to pay for the skilled nursing services provided from February 11, 2020 to February 17, 
2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for shoulder orthosis (L3670) provided to the enrollee on April 
15, 2020. 
 
You asked the Plan to pay for the orthosis. You say that the durable medical equipment is medically necessary. 
The Plan denied your request. The Plan says they were unable to discover any evidence of an established 
relationship between the member and the ordering physician. The Plan states there were no claims submitted 
for an evaluation and management service. The Plan states the review of claims history for this member, and a 
review of the submitted documentation does not contain evidence of a prior Telemedicine or Telehealth service 
with the ordering physician as required per CMS guidelines. 
 
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 pay for the orthosis. Our reviewer says that the 
enrollee does not meet criteria for the orthosis ordered. Our physician reviewer found based on the medical 
records provided there is no documentation that the L3670 shoulder orthosis, acromio/clavicular at issue in this 
case medically reasonable and necessary. The provided medical records do not clearly document either a face 
to face examination or a telehealth visit between the ordering provider and the patient. The records do not 
clearly document evidence of an established relationship between the enrollee and the ordering physician. 
 
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 orthosis have not been met. Therefore, we decided that the Plan does not 
have to pay for shoulder orthosis (L3670) provided to the enrollee on April 15, 2020.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the drug testing rendered on July 30, 2019. 
 
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says there is no valid physician order. 
 
The Plan must follow Medicare rules. Medicare rules say that lab testing generally must be ordered by a 
physician who has furnished a consultation or treats an enrollee for a specific medical problem.  
 
The file does not contain documentation of an established relationship between the enrollee and the ordering 
provider. Without a record showing that this provider is treating the enrollee, the criteria for coverage of this 
testing have not been met. Therefore, we decided that the Plan does not have to pay for the drug testing 
rendered on July 30, 2019.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the services (CPT 99285) provided on February 24, 2020. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says there is a more 
appropriate code for the services provided. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
In this case, the CPT Code Manual definition of code 99285 is "Emergency department visit for the evaluation 
and management of a patient, which requires these 3 key components within the constraints imposed by the 
urgency of the patient's clinical condition and/or mental status: A comprehensive history; A comprehensive 
examination; and Medical decision making of high complexity. Counseling and/or coordination of care with 
other physicians, other qualified health care professionals, or agencies are provided consistent with the nature 
of the problem(s) and the patient's and/or family's needs. Usually, the presenting problem(s) are of high 
severity and pose an immediate significant threat to life or physiologic function." 
 
We asked our coding 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 pay for the services. Our reviewer says that the use 
of CPT code 99285 is not supported by the records provided. Our coding reviewer found that the submitted 
documentation does not support the level of a comprehensive or detailed evaluation. There is a more 
appropriate code that should be used. 
 
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 services have not been met. Therefore, we decided that the Plan does not 
have to pay for the services (CPT 99285) provided on February 24, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the services (01402) provided on November 21, 2019. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the billed code cannot 
be verified. 
 
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 01402 is "Anesthesia for open or surgical arthroscopic 
procedures on knee joint; total knee arthroplasty". 
 
We asked our coding 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 pay for the services. Our reviewer says that the use 
of code 01402 is not supported by the records provided. Our coding reviewer found that the submitted 
documentation did not include anesthesia for total knee arthroplasty. The operative report documents a Left 
reverse left total shoulder arthroplasty, biceps tenodesis. Therefore CPT 01402 cannot be verified. 
 
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 services have not been met. Therefore, we decided that the Plan does not 
have to pay for the services (01402) provided on November 21, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the services (CPT 99350) provided on September 12, 2019. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the services were 
billed incorrectly. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
We asked our coding 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 pay for the services. Our reviewer says that the use 
of CPT code 99350 is not supported by the records provided. Our coding reviewer found that submitted 
documentation includes a home visit performed by a Licensed Practical Nurse. Per Medicare guidelines for 
Home services, codes 99341-99350 require the presence of a physician.  A Home Visit cannot be billed by a 
physician, unless the physician was in the beneficiary's home. 
 
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 services have not been met. Therefore, we decided that the Plan does not 
have to pay for the services (CPT 99350) provided on September 12, 2019.
Appeal type: Inpatient Hospital
Decision: Favorable

 
We decided that the Plan has to pay for the acute inpatient hospital care provided from January 10, 2020, to 
January 28, 2020. 
 
You asked the Plan to pay for the acute inpatient hospital care. The Plan denied your request. The Plan says 
that the enrollee's needs could have been met a lower level of care. 
 
The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor 
expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases, 
consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or 
more. 
 
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 pay for the acute inpatient hospital care. Our 
reviewer says that the documentation supports that the criteria for inpatient payment are met in this case. Our 
physician reviewer found that the enrollee presented with worse than baseline mental status, leukocytosis, and 
abnormal vitals, which suggested a complicated UTI, possibly sepsis, which would have warranted at least a 
two-midnight stay. This admission was appropriate based on the provided documentation. 
 
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 acute inpatient hospital care have been met. Therefore, we decided that the 
Plan has to pay for the acute inpatient hospital care provided from January 10, 2020, to January 28, 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: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pay for home infusion therapy (99601) provided on March 5, 2020. 
 
You asked the Plan to pay for the home infusion therapy. You say that you would like reconsideration based on 
the records submitted. The Plan denied your request. The Plan says CPT code 99601 has a status indicator of I 
which is not valid for Medicare purposes. 
 
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 99601 is not supported in the record. Specifically, per the Physician Fee Schedule, CPT 
code 99601 has a status indicator of I. This means that CPT code 99601 is not valid for Medicare purposes. 
Based on this information, we decided that Medicare rules for coverage of the home infusion therapy have not 
been met. Therefore, we decided that the Plan does not have to pay for home infusion therapy (99601) provided 
on March 5, 2020.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve ambulance transport for the enrollee. 
 
You asked the Plan to pre-approve ambulance transport. You say that that the member has a life threatening 
condition and it is impossible to safely transport him by any other means. The Plan denied your request. The 
Plan says that transportation by ambulance to a physician?s office is not a covered benefit. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for ambulance transports only when 
they meet certain origin and destination requirements. A doctor?s office is not a covered destination.  
 
The services you have asked the Plan to pre-approve are ambulance transport services to a doctor?s office. 
Therefore, we decided that the Plan does not have to pre-approve ambulance transport for the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for specialist services provided by a 
participating provider on January 9, 2020. 
 
You asked the Plan to waive the copayment for specialist services. You say that you do not agree with these 
charges. The Plan denied your request. The Plan says the correct copayment 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 
copayment for physician/practitioner services/specialist.  
 
You have been asked to pay $10.36 which is less than your copayment amount of $20 for specialist services. 
Specialist services fall within the physician/practitioner services/specialist benefit category. The correct 
copayment has been applied to the services that were provided. 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 specialist services provided a participating provider on January 9, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an ankle-foot orthosis (L1971) provided to the enrollee on 
March 17, 2020. 
 
You asked the Plan to pay for the orthosis. You say that the claim should be paid. The Plan denied your 
request. The Plan says the documentation does not indicate services are necessary for treatment of the 
enrollee's condition. 
 
The Plan must follow Medicare rules. Medicare rules say that for eligible telehealth services, 
telecommunications systems substitute for an in-person encounter. Medicare enrollees are eligible for 
telehealth services only if they are presented from an authorized originating site located in either a county 
outside of a Metropolitan Statistical Area (MSA) or a rural Health Professional Shortage Area (HPSA) located 
in a rural census tract. 
  
A review of the file does not show that the telehealth service was provided in an authorized originating site. 
This means that the telehealth visit is not a covered service under the Medicare program and cannot substitute 
for an in-person encounter. Consequently, the items/services ordered following the noncovered visit are 
likewise noncovered. Therefore, we decided that the Plan does not have to pay for an ankle-foot orthosis 
(L1971) provided to the enrollee on March 17, 2020.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for surgical services provided to the enrollee on January 22, 
2020 and billed under code 63030. 
 
You asked the Plan to pay this claim as billed. You say that this claim should be paid. The Plan denied your 
request. The Plan says the Medicare billing guidance says "Procedure code 63030 is not supported by the medical 
records submitted. The operative report did not include documentation of a laminotomy (hemilaminectomy) with 
decompression of nerve root(s), including partial facetectomy, foraminotomy and/or excision of herniated intervertebral 
disc, for 1 lumbar interspace; therefore, this code cannot be verified." The Plan states the requested service code is not 
substantiated by the clinical documentation submitted for review and is therefore is denied.  
 
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 specific code submitted is not 
supported by the limited medical records received. Based on this information, we decided that Medicare rules 
for coverage of this claim as billed have not been met. Therefore, we decided that the Plan does not have to pay 
for surgical services provided to the enrollee on January 22, 2020 and billed under code 63030.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the medical services provided on January 6, 2020 by an out 
of network provider. 
 
You asked the Plan to pay for subsequent nursing facility care (99308). You say that the encounter was 
medically necessary. The Plan denied your request. The Plan says necessity for an out-of-network provider has 
not been 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 has network providers 
available who can provide the services 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 these services. Therefore, we decided that the 
Plan does not have to pay for the medical services provided on January 6, 2020 by an out of network provider.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to issue reimbursement of the copayment for the positron emission 
tomography (PET) scan (78815) provided on January 24, 2020. 
 
You asked the Plan to issue reimbursement of the copayment. You say that you are requesting a 
reconsideration of the Plan's denial for payment. The Plan denied your request. The Plan says the copayment 
has been applied correctly to the service provided. 
 
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 in-network advanced imaging services provided in a PCP?s or Specialist?s office.  
 
You have been asked to pay a $150 copayment for the advanced imaging service provided by an in-network 
specialist. 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 issue reimbursement of the copayment for the positron emission 
tomography (PET) scan (78815) provided on January 24, 2020.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an ambulance transport (A0429, A0425) 
provided March 21, 2020. 
 
You asked the Plan to waive the copayment for the ambulance transport. You say that since you didn't call the 
ambulance the copayment should be waived. The Plan denied your request. The Plan says the correct 
copayment was applied since the services were rendered. 
 
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 $200 
copayment for Ambulance Services.  
 
You have been asked to pay a $200 copayment for the ambulance transport. The ambulance transport falls 
within the Ambulance 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 
an ambulance transport (A0429, A0425) provided March 21, 2020.
Appeal type: Drugs
Decision: Favorable

 
We decided that the Plan has to pre-approve Rituxan 
 
You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied 
your request. The Plan says that the services are not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for a drug or biological only if it is safe 
and effective and otherwise reasonable and 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 these services. Our reviewer says that 
the services are medically necessary. Our physician reviewer found the enrollee has a diagnosis of 3A follicular 
lymphoma transformed to HGBCL triple hit. Rituximab is a standard part of treatment for both initial and 
subsequent treatment of diffuse large B-cell lymphoma. The plan is for the enrollee to receive salvage 
chemotherapy with rituximab in combination with chemotherapy (R-ICE) prior to possible enrollment on a 
clinical trial. This is a standard of care. The regimen is not part of a clinical trial. The service is reasonable and 
medically 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 these services have been met. Therefore, we decided that the Plan has to pre-
approve Rituxan  
 
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.