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

 
We decided that the Plan does not have to pay for CPT codes 29826 and 29827 provided on June 21, 2019. 
 
You asked the Plan to pay for CPT codes 29826 and 29827. You say that the medical records support the 
billing of CPT codes 29826 and 29827. The Plan denied your request. The Plan says the medical records do not 
support the billing of CPT codes 29826 and 29827. 
 
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 29826 is Arthroscopy, shoulder, surgical; decompression 
of subacromial space with partial acromioplasty, with coracoacromial ligament (ie, arch) release, when 
performed (List separately in addition to code for primary procedure). The CPT Code Manual definition of 
code 29827 is Arthroscopy, shoulder, surgical; with rotator cuff repair. 
 
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 CPT codes 29826 and 29827. Our reviewer 
says that the medical records do not support the billing of CPT codes 29826 and 29827. Our physician reviewer 
found in this case, the operative report does not document that a rotator cuff repair nor a acromioplasty was 
performed.  Therefore the codes are not supported. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of CPT codes 29826 and 29827 have not been met. Therefore, we decided that the 
Plan does not have to pay for CPT codes 29826 and 29827 provided on June 21, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the Zoster (shingles) vaccine and immunization 
administration provided on September 30, 2019 and December 16, 2019. 
 
You asked the Plan to pay for Zoster (shingles) vaccine (90750) and Immunization administration (90471). 
You say that the enrollee does not have the money to pay the charge upfront. The Plan denied your request. 
The Plan says the vaccine is not covered under the enrollee's Medicare Part B benefit. 
 
In the absence of injury or direct exposure to illness, Medicare does not pay for or provide the Zoster (shingles) 
vaccine (90750) or Immunization administration (90471). The Plan follows the same rules.  
 
Records do not show that the enrollee been injured or directly exposed to any illness related to the Zoster 
(shingles) vaccine (90750) and Immunization administration (90471). Therefore, we decided that the Plan does 
not have to pay for the Zoster (shingles) vaccine and immunization administration provided on September 30, 
2019 and December 16, 2019.  
 
Benefits for Zoster (shingles) vaccine (90750) and Immunization administration (90471) may be available 
under Medicare Part D. Contact the Plan that administers Part D benefits for further information concerning 
any benefits and appeal rights.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pay for skilled nursing facility (SNF) care provided from 
 
You asked the Plan to pay for SNF care. You say that this should be covered by Medicare. 
 The Plan denied your request. The Plan says no skilled services were provided. 
 
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 SNF care. Our reviewer says that daily 
skilled services are not necessary. Our physician reviewer found the records do not show that the enrollee had 
any identifiable skilled nursing service needs during the dates at issue. He received oral medications and 
insulin.  The beneficiary had stable vital signs. He was alert and forgetful.  He had no pain and was monitored 
after a fall. Regarding rehabilitation services, the beneficiary did not receive or require any skilled services for 
the dates in question. This beneficiary does not meet severity of illness or intensity of service criteria for an 
inpatient basis in a skilled nursing facility 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 SNF care have not been met. Therefore, we decided that the Plan does not have 
to pay for skilled nursing facility (SNF) care provided from
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to issue reimbursement of the copayment for the computed tomography 
(CT) scan of the thorax (71250) provided on March 31, 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 $125 
copayment for each Medicare-covered radiological diagnostic service, not including x-rays, performed in a 
physician's office or at a free-standing facility (such as a radiology center or medical clinic).  
 
You have been asked to pay a $112.09 copayment for the Medicare-covered radiological diagnostic service 
provided. This is the Plan allowed amount which is less than the applicable copayment. 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 computed tomography (CT) scan of the thorax 
(71250) provided on March 31, 2020.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for Comprehensive Genomic Profile (CGP) testing provided to 
the enrollee on April 16, 2020. 
 
You asked the Plan to pay for the testing. You say that this should be paid for. The Plan denied your request. 
The Plan says Comprehensive Genomic Profile (CGP) testing (i.e. Guardant-360? and NEXT-Generation?) 
requires use of CPT 81479. 
 
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 the various denied CPT codes are not supported in the medical record. Specifically, the testing at 
issue in this case should be reported with CPT 81479. Based on this information, we decided that Medicare 
rules for coverage of the testing have not been met. Therefore, we decided that the Plan does not have to pay 
for Comprehensive Genomic Profile (CGP) testing provided to the enrollee on April 16, 2020.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for reconstruction of nail bed with graft (CPT Code 11762) and 
partial excision (craterization, saucerization, sequestrectomy, or diaphysectomy) bone (eg, osteomyelitis or 
bossing); phalanx of toe (CPT Code 28124) provided on February 18, 2020. 
 
You asked the Plan to pay for the services. 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 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 services. Our physician reviewer found 
after careful review of enclosed medical documentation and information, the CPT codes billed by this provider 
are not supported by the medical records. On February 18, 2020, this patient underwent matrixectomies of 
bilateral hallux toes. The provider billed CPT code 11762  reconstruction of nail bed with graft, as well as 
CPT code 28124  partial excision ( craterization, saucerization, sequestrectomy, or diaphysectomy), bone(eg. 
osteomyelitis or bossing) phalanx of toe. The operative note (February 18, 2020) enclosed in this chart does not 
advise that any bone was resected from the phalanges, nor does it advise on any reconstruction of the nail bed 
with the use of a graft. Therefore, the medical records do not support the billing for CPT code 11762 or CPT 
code 28124. 
 
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 services have not been met. Therefore, we decided that the Plan does not 
have to pay for reconstruction of nail bed with graft (CPT Code 11762) and partial excision (craterization, 
saucerization, sequestrectomy, or diaphysectomy) bone (eg, osteomyelitis or bossing); phalanx of toe (CPT 
Code 28124) provided on February 18, 2020.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for laboratory testing provided on October 8, 2019. 
 
You asked the Plan to pay for lab tests. You say that you are appealing with a signed physician order. The Plan 
denied your request. The Plan says the denial of payment for these services is correct, because the 
documentation submitted does not include a valid physician order, lab requisition, or medical records stating 
exactly which tests were to be performed. 
 
The Plan must follow Medicare rules. Medicare rules say that a physician order or clear intent to order specific 
lab services is required for covered lab services.  
 
We looked at the file and Medicare rules. The documentation submitted does not include a valid physician 
order or clear intent to order the specific lab services billed on this claim. Based on this information, we 
decided that Medicare rules for coverage of lab tests have not been met. Therefore, we decided that the Plan 
does not have to pay for laboratory testing provided on October 8, 2019.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the outpatient individual psychotherapy, 45 minutes (90834) 
provided from October 17, 2019 to March 12, 2020 by an out of network (OON) provider. 
 
You asked the Plan to pay for the outpatient psychotherapy. You say that you believe there was an approved 
referral on file for you to see this provider. The provider has now stopped seeing you since the plan is not pay 
the claims and you would like to continue services. The Plan denied your request. The Plan says this provider is 
not licensed or certified by Medicare. 
 
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. Except for emergency care, the plan cannot pay a provider who 
is not eligible to participate in Medicare. If you go to a provider who is not eligible to participate in Medicare, 
you will be responsible for the full cost of the services you receive. 
 
The services at issue in this appeal were provided in a non-urgent, non-emergent situation by the provider. The 
provider is not eligible to participate in Medicare. 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 outpatient individual 
psychotherapy, 45 minutes (90834) provided from October 17, 2019 to March 12, 2020 by an out of network 
(OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the Physician specialist service provided on 
March 3, 2020 and March 17, 2020. 
 
You asked the Plan to waive the copayment for the copayment for the Physician specialist service. You say that 
the services should not have a copayment. The Plan denied your request. The Plan says they will change the 
copayment for the outpatient surgery of March 17, 2020 to $45 but you have been charged the Physician 
specialist service correctly for date of service March 3, 2020. 
 
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 $45 
copayment for the office visit and a $275 copayment for outpatient surgery. 
 
You have been asked to pay a $45 copayment for the Physician specialist services. The copayment for the 
Physician specialist service falls within the Physician Specialist 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 the Physician specialist service provided on March 3, 2020 and 
March 17, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the destruction of premalignant lesions, 15 or more lesions 
(17004) rendered by the out of network (OON) provider on February 10, 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 destruction of premalignant lesions, 15 or more lesions (17004) rendered by the out of 
network (OON) provider on February 10, 2020.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home health services provided to the enrollee on March 
27, 2020 and April 8, 2020. 
 
You asked the Plan to pay for home health services. You say that the Plan should pay this claim. The Plan 
denied your request. The Plan says you omitted the treatment authorization code. 
 
The Plan must follow Medicare rules. The rules say that certain data elements on the RAP and the claim must 
be completed for home health care services to be covered. 
 
We looked at the claim submitted, the file and the Medicare rules. Based on this information, we decided that 
Medicare rules for completing the claim for home health services have not been met. Specifically, a valid 18 
digit alphanumeric Treatment Authorization Code is missing from the claim. Also, the enrollee was not 
enrolled in the Plan on the April 8, 2020 date of service in question. Therefore, we decided that the Plan does 
not have to pay for the home health services provided to the enrollee on March 27, 2020 and April 8, 2020.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for CPT code A0432 provided on May 16, 2019. 
 
You asked the Plan to pay for CPT code A0432. 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. Medicare rules say that providers must report services correctly. 
 
We looked at the file and Medicare rules. Medicare says ambulance claims need to be edited to assure the 
presence of an origin, destination modifier, and a QM or QN modifier for every line item containing revenue 
code 540. The file shows that the claim was not billed with either a QM or QN modifier. Therefore, we decided 
that the Plan does not have to pay for CPT code A0432 provided on May 16, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for outpatient hospital services provided on March 31, 2020. 
 
You asked the Plan to pay for the outpatient hospital services. The Plan denied your request. The Plan says 
non-emergent, non-urgent services with out-of-network providers require 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 requested provider in this case is not a network provider with the Plan. The Plan did not pre-approve the 
services 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 outpatient hospital services provided on March 31, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for durable medical equipment items (A4349, A4353, A4927, 
A5120) provided May 28, 2019. 
 
You asked the Plan to pay for the durable medical equipment. You say that the items were medically necessary. 
The Plan denied your request. The Plan says the documentation does not support the items 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 for the supplies provided in this case. An itemized invoice 
was not included. 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 durable medical equipment items 
(A4349, A4353, A4927, A5120) provided May 28, 2019.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the acute inpatient hospital care provided from May 10, 2019 
to May 11, 2019. 
 
You asked the Plan to pay for acute inpatient hospital care. You say that this was medically necessary. The 
Plan denied your request. The Plan says there was not a need for monitoring beyond observation 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 acute inpatient hospital care. Our reviewer 
says that the documentation does not support that the criteria for inpatient payment are met in this case. Our 
physician reviewer found the enrollee presented to the emergency room after a fall with leg injury. He was 
found to have low blood sugar. On exam his vital signs were normal and his mental status was normal. X-rays 
revealed no fracture. He was treated with Dextrose and admitted. He was monitored overnight and left the next 
day. He had no further hypoglycemia. The review has determined that the record did not show that at the time 
of inpatient admission the admitting physician reasonably expected that the patient's necessary hospital care 
would span two midnights. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of acute inpatient hospital care have not been met. Therefore, we decided that the 
Plan does not have to pay for the acute inpatient hospital care provided from May 10, 2019 to May 11, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for physician's services that you provided on January 7, 2020, 
January 9, 2020 and January 14, 2020. 
 
You asked the Plan to pay for the physician's services. The Plan denied your request. The Plan says the Plan 
requires utilization of network providers when possible and available, and requires authorization for certain 
services. No medical necessity for an out-of-network provider, such as an urgent or emergency situation, has 
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 did not pre-approve the 
services 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 physician's services that you provided on January 7, 2020, 
January 9, 2020 and January 14, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a special service (99190), miscellaneous medical equipment 
(E1399), infection control supplies (S8301), an IV pole (E0776), and an infusion pump (E0780) provided on 
March 16, 2020. 
 
You asked the Plan to pay for a special service, miscellaneous medical equipment, infection control supplies, 
an IV pole, and an infusion pump. You say that these codes are supported in the records. The Plan denied your 
request. The Plan says the documentation is not sufficient to support these codes. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. The rules also say that all claims for Durable 
Medical Equipment, Prosthetic, and Orthotic Supplies (DMEPOS) require a written order/prescription from the 
treating practitioner. The supplier must keep the order and proof of delivery documentation on file. 
 
We find that these CPT codes are not supported. Specifically, 99190 and E1399 are miscellaneous codes. It is 
not indicated in the medical record the specific items and services they are being used to report. Code S8301 
has a status indicator of ?I.? Medicare uses another code for reporting of, and payment for these services. 
Codes E0776 and E0780 are not supported because the file does not contain a proof of delivery showing these 
items were dispensed to the enrollee. Based on this information, we decided that Medicare rules for coverage of 
a special service, miscellaneous medical equipment, infection control supplies, an IV pole, and an infusion 
pump have not been met. Therefore, we decided that the Plan does not have to pay for a special service 
(99190), miscellaneous medical equipment (E1399), infection control supplies (S8301), an IV pole (E0776), 
and an infusion pump (E0780) provided on March 16, 2020.