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

 
We decided that the Plan does not have to pay for the outpatient office visit (99214) and smoking and tobacco 
use cessation counseling (99406) provided on May 4, 2020, by an out of network (OON) provider. 
 
You asked the Plan to pay for office visit and tobacco use cessation counseling. You say that prio0r 
authorization is not needed for telemedicine. The Plan denied your request. The Plan says prior authorization 
must be obtained for non-emergent services rendered by an out-of-network provider. 
 
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 outpatient office visit (99214) and smoking 
and tobacco use cessation counseling (99406) provided on May 4, 2020, by an out of network (OON) provider.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Stomach Intestinal Pylorus Sparing (SIPS) bariatric 
procedure. 
 
You asked the Plan to pre-approve the SIPS procedure. The Plan denied your request. The Plan says this is not 
medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the SIPS procedure. Our reviewer says 
that the requested services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found that the requested SIPS procedure is a not a standard covered procedure by CMS and remains 
investigational at this time. 
 
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 SIPS procedure have not been met. Therefore, we decided that the Plan does 
not have to pre-approve a Stomach Intestinal Pylorus Sparing (SIPS) bariatric procedure.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the medical services provided to the enrollee by an out-of-
network provider on June 18, 2020. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the services were not 
authorized. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The 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 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 the medical services provided to the enrollee by an out-of-network provider 
on June 18, 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 from 
March 8, 2019 to March 21, 2019. 
 
You asked the Plan to pay for home health services. You say that you would like reconsideration based on the 
records submitted. The Plan denied your request. The Plan says the submitted claim requires a treatment 
authorization code and date of admission. 
 
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, the claim 
that was submitted does not include the required treatment authorization code. Therefore, we decided that the 
 
 
Plan does not have to pay for the home health services provided to the enrollee from March 8, 2019 to March 
21, 2019.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ambulance services provided on February 26, 2020. 
 
You asked the Plan to pay for the ambulance services. The Plan denied your request. The Plan says this is not a 
covered service. 
 
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 February 26, 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 on February 26, 
2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve stab phlebectomy. 
 
You asked the Plan to pre-approve stab phlebectomy. You say that you feel that this is medically necessary. 
The Plan denied your request. The Plan says the denial of authorization for this service is correct, because this 
procedure is not covered unless there is associated bleeding. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve stab phlebectomy. Our reviewer says 
that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found the enrollee had multiple previous procedures on her veins. Only 4 days after she 
completed her last procedure, she was concerned about the cosmetic appearance of her legs and there is 
mention of a bulging on her leg. It is not clear why this vein did not bother the enrollee 4 days prior. At this 
point the enrollee was already post 2 venous procedures on the same leg within a 3-week period. As the 
enrollee has not had a reasonable period of time of conservative treatment since her most recent procedure, the 
documentation does not support the medical necessity of this procedure. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of stab phlebectomy have not been met. Therefore, we decided that the Plan does 
not have to pre-approve stab phlebectomy.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the lab services provided on November 12, 2019. 
 
You asked the Plan to pay for the lab 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 find that the requested CPT codes are not supported in the medical record. Specifically, the records do not 
support the specimen was collected by venipuncture. The records show that a urine sample was collected. 
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 the lab services provided on November 12, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the eyewear you received on June 12, 2020. 
 
You asked the Plan to pay for the eyewear. The Plan denied your request. The Plan says the benefit limit has 
been reached. 
 
Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine 
vision and eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in 
this case. The Plan covers these services when up to $100 every year. 
 
We looked at the file and the Plan's rules. The records show that the Plan paid $100 toward your eyewear for 
2020. This means that the benefit limit has been reached and you are responsible for any amount over $100. 
Based on this information, we decided that the Plan's rules for coverage of the eyewear have not been met. 
Therefore, we decided that the Plan does not have to pay for the eyewear you received on June 12, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the lumbar orthosis provided on April 15, 2020. 
 
You asked the Plan to pay for the lumbar orthosis. 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 are both a 
physician order and proof of delivery.  
 
The record does not contain a valid physician order or relevant medical records which support medical 
necessity 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 
lumbar orthosis provided on April 15, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for physician services provided to the enrollee on March 18, 
2020. 
 
You asked the Plan to pay for this service. You say that this claim should be paid. The Plan denied your 
request. The Plan says the enrollee did not have prior authorization for out of network care. 
 
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 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 physician services provided 
to the enrollee on March 18, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for physician services provided to the enrollee on February 11, 
2020 and billed under code 00400 with diagnosis code Z53.8.  
 
You asked the Plan to pay for this service. You say that this claim should be paid. The Plan denied your 
request. The Plan says Procedure code 00400 submitted with primary diagnosis Z53.8 was denied because the 
primary diagnosis code billed for the procedure is not appropriate. 
 
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, based on review of the Medicare 
coding guidelines, the procedure code billed is not appropriate for the diagnosis code reported. Medicare rules 
for coverage of this service have not been met. Therefore, we decided that the Plan does not have to pay for 
physician services provided to the enrollee on February 11, 2020 and billed under code 00400 with diagnosis 
code Z53.8.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not haveto pay fora continuous glucose monitor provided to the enrollee on April 18, 2020.You asked the Planto pay forthe monitor. You say that this should be paid for.The Plandenied your request. The Plansaysthe medical records provided do not indicate that the ordering provider discussed with theenrollee the ordering of a glucose monitor.The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pay for the monitor. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found the review has determined that the monitor is not considered therapeutic. There is no documented diagnosis of diabetes mellitus. The enrollee has not been using insulin multiple times (3 or more) a day. The treatment does not require frequent adjustment on the basis of testing results.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 monitor have not been met.Therefore, we decided that the Plandoes not haveto pay fora continuous glucose monitor provided to the enrollee on April 18, 2020
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for ambulance services provided. 
 
You asked the Plan to waive the copayment for ambulance services. You say that you cannot afford the 
charges. The Plan denied your request. The Plan says the claims were processed correctly and you are being 
charged the correct amount. 
 
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 $270 
copayment for ambulance services.  
 
You have been asked to pay a $270 copayment for ambulance services. Ambulance services fall 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 ambulance services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for DME provided on February 19, 2020. 
 
You asked the Plan to pay for the DME. The Plan denied your request. The Plan says that 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 
DME items. We found no exception that would require the Plan to pay for these items. Therefore, we decided 
that the Plan does not have to pay for DME provided on February 19, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve incontinence supplies. 
 
You asked the Plan to pre-approve incontinence supplies. You say that you're unable to keep up with this 
monthly cost. The Plan denied your request. The Plan says this item is not a covered benefit. 
 
The Plan covers all items that Medicare covers. Medicare rules state that incontinence supplies are not covered 
because they are hygienic items that are non-reusable.  
 
While incontinence supplies may be appropriate in this case, neither the Plan nor Medicare offers coverage of 
these items. Therefore, we decided that the Plan does not have to pre-approve incontinence supplies.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for spirometry (94010) and diffusing capacity testing (94729) 
provided on December 11, 2019. 
 
You asked the Plan to pay for spirometry and diffusing capacity testing. You say that this was billed correctly. 
The Plan denied your request. The Plan says this was not billed with the required modifier. 
 
The Plan must follow Medicare rules. Medicare rules say that carriers may not pay for the technical component 
(TC) of radiology services furnished to hospital patients. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of spirometry and diffusing capacity testing have not been met. Specifically, these services have both 
a professional and technical component. This means that modifiers should be used with these codes as the 
technical component is paid to the hospital. Therefore, we decided that the Plan does not have to pay for 
spirometry (94010) and diffusing capacity testing (94729) provided on December 11, 2019.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) services. 
 
You asked the Plan to pre-approve the SNF services. You say that the enrollee is currently in the hospital and 
would benefit from continued therapy due to debility. The Plan denied your request. The Plan says the 
guidelines for coverage of SNF care have not been met. 
 
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 pre-approve the SNF services. Our reviewer says 
that daily skilled services are not necessary. Our physician reviewer found the enrollee received oral and 
inhaled medications. The enrollee had stable vital signs and was treated for bronchitis and pneumonia. The 
enrollee received physical therapy and occupational therapy in the acute hospital. The enrollee was at a stand 
by assist to contact guard level with functional mobility, including gait to a few feet. The enrollee required 
varying assist with activities of daily living. There are no identifiable skilled nursing service needs. 
There are identifiable skilled therapy service needs, but they are not required on a daily basis. The enrollee 
does not meet the severity of illness or intensity of service criteria for 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 SNF services have not been met. Therefore, we decided that the Plan does 
not have to pre-approve skilled nursing facility (SNF) services.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve bone marrow harvesting for transplantation and 
hematopoietic progenitor cell (HPC); autologous transplantation for the enrollee. 
 
You asked the Plan to pre-approve the services. You say that this is medically necessary. The Plan denied your 
request. The Plan says this is not supported for use in lumbar spine fusion procedures. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the services. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found bone marrow aspirate remains experimental for use in spinal fusion surgery. More research is needed to 
show safety and efficacy. 
 
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 pre-approve bone marrow harvesting for transplantation and hematopoietic progenitor cell (HPC); 
autologous transplantation for the enrollee.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the injection services coded 20552 provided on July 9, 2019. 
 
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 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. 
 
In this case, the CPT Code Manual definition of code 20552 is injection(s); single or multiple trigger point(s), 1 
or 2 muscle(s). 
 
We find that CPT code 20552 is not supported in the medical record. Specifically, this service is not a bilateral 
procedure; therefore, it should not be billed with modifiers RT or LT. This code was billed with modifier RT. 
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 20552 provided 
on July 9, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a consultation (D9310). 
 
You asked the Plan to pre-approve the dental service. You say that you are new to this plan. You also say that 
you have not received this service yet. The Plan denied your request. The Plan says the requested dental service 
is covered once every 6 months. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plan?s coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage and consultations are a covered service, 
the frequency limit of once every 6 months has been reached. The record shows you had an oral exam on July 
1, 2020. Therefore, we decided that the Plan does not have to pre-approve a consultation (D9310).