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

 
We decided that the Plan does not have to pay for the echocariography coded 93308 and 93306 provided on 
February 27, 2020. 
 
You asked the Plan to pay for the echocariography. 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 payable. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
We find that CPT codes 93308 and 93306 are not supported in the medical record. Specifically, the same CPT 
codes (99308 and 99306) have been billed on a different claim by the same provider for the same date of 
service. In order to show that the same procedures were performed twice on the same day on different sessions, 
the documentation is required for both procedures. Based on this information, we decided that Medicare rules 
for coverage of the echocariography have not been met. Therefore, we decided that the Plan does not have to 
pay for the echocariography coded 93308 and 93306 provided on February 27, 2020.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for ambulance services provided on May 5, 2020. 
 
You asked the Plan to pay for the ambulance services. You say that the claim should be paid. The Plan denied 
your request. The Plan says the member was enrolled in hospice at the time of services. The Plan states per 
Medicare guidelines, the member's services should be billed under Original Medicare. 
 
Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice 
services. Medicare hospice pays for claims related to the terminal illness. The rules say that the Plan may direct 
the provider to bill Medicare directly for these services.  
 
The enrollee was under the Medicare hospice benefit for the dates of service at issue in this appeal. The 
member has been enrolled in hospice from September 26, 2019 to current. Therefore, we decided that the Plan 
does not have to pay for ambulance services provided on May 5, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for wound care services provided on January 22, 2020. 
 
You asked the Plan to pay for the wound care services. The Plan denied your request. The Plan says the wound 
care visits were for services that were foreseen, not urgent or emergent, available in area and not prior 
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 did not pre-approve the 
wound care services. 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 wound care services provided on January 22, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for wound care services provided on January 3, 2020. 
 
You asked the Plan to pay for the wound care services. The Plan denied your request. The Plan says the wound 
care visit was for services that were foreseen, not urgent or emergent, available in area and not prior 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 did not pre-approve the 
wound care services. 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 wound care services provided on January 3, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the arthroplasty surgical assistant services provided on 
March 5, 2020. 
 
You asked the Plan to pay for the surgical assistant services. You say that the provider is a licensed Surgical 
Assistant. The Plan denied your request. The Plan says surgical technicians are not separately reimbursable. 
 
The Plan follows Medicare rules. The rules say that Medicare only pays for assistant surgery services when the 
procedure is covered for an assistant and the person who assists the surgery bears the designation of a 
physician, PA, NP, or CNS. 
 
In this case, the record does not show that the provider of the surgical assistant service is a physician, PA, NP, 
or CNS. Medicare only makes payment for surgical assistant services when provided by one of these types of 
practitioners. Therefore, we decided that the Plan does not have to pay for the arthroplasty surgical assistant 
services provided on March 5, 2020.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services (80053, 80074, 85025, 81001, 86780, 
86701, 84443) rendered by the out of network (OON) provider on March 2, 2020. 
 
You asked the Plan to pay for these services. You say that you are requesting a reconsideration of the Plan's 
denial for payment. The Plan denied your request. The Plan says the services were 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 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 laboratory services (80053, 80074, 85025, 81001, 86780, 86701, 84443) rendered 
by the out of network (OON) provider on March 2, 2020.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pay for physician's services provided on October 2, 2019. 
 
You asked the Plan to pay for the physician's services. 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 
physicians services. 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 provided on October 2, 2019.
Appeal type: Hospice
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the hospice or home health care provided in the enrollee's 
home/residence, services of home health/hospice aide in home health or hospice settings, direct skilled nursing 
services of a RN in the home health or hospice setting, and direct skilled nursing services of a LPN in the home 
health or hospice setting provided from April 1, 2020 to April 28, 2020. 
 
You asked the Plan to pay for the hospice or home health care services. You say that you felt ill and were 
transported to the hospice by medical services without your consent. You also say that you feel you should not 
be responsible. The Plan denied your request. The Plan says hospice care is paid through Original Medicare 
and not by the Plan. 
 
Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice 
services. Medicare hospice pays for claims related to the terminal illness. The rules say that the Plan may direct 
the provider to bill Medicare directly for these services.  
 
The enrollee was under the Medicare hospice benefit for the dates of service at issue in this appeal. Therefore, 
we decided that the Plan does not have to pay for the hospice or home health care provided in the enrollee's 
home/residence, services of home health/hospice aide in home health or hospice settings, direct skilled nursing 
services of a RN in the home health or hospice setting, and direct skilled nursing services of a LPN in the home 
health or hospice setting provided from April 1, 2020 to April 28, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayments for the urology office visit (99213) and the 
ophthalmological services (92014) provided on June 22, 2020 and June 25, 2020. 
 
You asked the Plan to waive the copayments. You say that you are requesting a reconsideration of the Plan's 
denial for payment. The Plan denied your request. The Plan says the copayments have been applied correctly to 
the services 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 $30 
copayment for each visit to a specialist.  
 
You have been asked to pay $60 ($30 copayment x 2) for the visits to a 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 waive the copayments for the urology office visit (99213) and the ophthalmological services (92014) 
provided on June 22, 2020 and June 25, 2020.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the skilled nursing services provided from January 1, 2020 to 
January 30, 2020. 
 
You asked the Plan to pay for the skilled nursing services. You say that the service which the enrollee required 
and received are coverable under the Medicare Act. The Plan denied your request. The Plan says the SNF 
services were not medically necessary. 
 
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 January 1, 2020 to January 30, 2020.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for drug testing provided on March 31, 2020. 
 
You asked the Plan to pay for drug testing. You say that you were told that the enrollee had in-network and 
out-of-network benefits and were not aware of authorization requirements. The Plan denied your request. The 
Plan says the denial of payment for this testing is correct, because the enrollee previously had this test on 
March 26, 2020 and this testing is not covered more than once per week. 
 
The Plan must follow Medicare rules. Medicare rules say that definitive urinary drug testing is not to exceed 1 
physician-directed testing profile in one week.  
 
We looked at the file and Medicare rules. Definitive urinary drug testing was performed previously on March 
26, 2020; therefore, this testing exceeds the frequency limitation according to Medicare rules. Based on this 
information, we decided that Medicare rules for coverage of drug testing have not been met. Therefore, we 
decided that the Plan does not have to pay for drug testing provided on March 31, 2020.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab work provided on September 4, 2019 by an out of 
network (OON) provider. 
 
You asked the Plan to pay for lab work. You say that you do not agree with these tests being denied. The Plan 
denied your request. The Plan says prior authorization was not obtained. The Plan says that the referring 
provider is also out-of-network. 
 
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 lab work provided on September 4, 2019 by an out 
of network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the rest home visit provided on June 1, 2020 by an out of 
network (OON) provider. 
 
You asked the Plan to pay for the rest home visit. You say that you would like the plan to reconsider their 
denial. The Plan denied your request. The Plan says the services rendered are not a covered benefit. 
 
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 rest home visit provided on June 1, 2020 by an 
out of network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for chiropractic services provided on June 3, 2020. 
 
You asked the Plan to pay for the chiropractic services. The Plan denied your request. The Plan says you must 
receive care from in-network providers with the exception of emergency or urgent care, dialysis while 
temporarily out of the plan's service area or if the care cannot be provided with an in-network provider, which 
requires prior authorization from the plan. 
 
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 chiropractic services provided on June 3, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the medical services provided on March 12, 2020 by an out 
of network (OON) provider. 
 
You asked the Plan to pay for the outpatient visit (99213 and G0467). You say that you would like 
reconsideration because the services were medically necessary and rendered in good faith. The Plan denied 
your request. The Plan says prior authorization was not obtained by the provider or facility. 
 
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 medical services provided on 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 pay for urology services received on May 8, 2020. 
 
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. 
The Plan says the provider is not contracted with the plan, and prior authorization is required. 
 
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 urology services received on May 8, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the unspecified preventive procedure or PPE provided on 
June 9, 2020. 
 
You asked the Plan to pay for the PPE. You say that the PPE protects the office team, but you were not 
provided with any protective materials. You also say that PPE should not be billed to you, because it is an 
obligation of the office team to make sure they are following all federal regulations. The Plan denied your 
request. The Plan says this service is not covered. 
 
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, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the 
unspecified preventive procedure or PPE provided on June 9, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the crown provided on June 15, 2020. 
 
You asked the Plan to pay for the crown. The Plan denied your request. The Plan says this service is not 
covered under your benefit plan. 
 
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, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the crown 
provided on June 15, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for CPT code 99497 provided on January 12, 2020. 
 
You asked the Plan to pay for CPT code 99497. 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. 
Providers must report services with the appropriate CPT code. 
 
In this case, the CPT Code Manual definition of code 99497 is Advance care planning including the 
explanation and discussion of advance directives such as standard forms (with completion of such forms, when 
performed), by the physician or other qualified health care professional; first 30 minutes, face-to-face with the 
patient, family member(s), and/or surrogate. 
 
We find that CPT code 99497 is not supported in the medical record. Specifically, CPT code 99497 is a time 
based code. In order to bill CPT code 99497, the documentation must note that the first 30 minutes were face-
to-face with the patient, family member(s), and/or surrogate for advance care planning. The progress note for 
January 12, 2020 does not note how much of the time spent was for advanced care planning. As such, the 
provided documentation does not support the billing of CPT code 99497. Based on this information, we 
decided that Medicare rules for coverage of CPT code 99497 have not been met. Therefore, we decided that the 
Plan does not have to pay for CPT code 99497 provided on January 12, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the sedation services provided on October 9, 2019. 
 
You asked the Plan to pay for the services provided. The Plan denied your request. The Plan says the billed 
service 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 99152 is Moderate sedation services provided by the 
same physician or other qualified health care professional performing the diagnostic or therapeutic service that 
the sedation supports, requiring the presence of an independent trained observer to assist in the monitoring of 
the patient's level of consciousness and physiological status. 
 
We find that CPT code 99152 is not supported in the medical record. Specifically, the records do not indicate 
the presence of an independent trained observer to assist in the monitoring of the patient's level of 
consciousness and physiological status. Based on this information, we decided that Medicare rules for coverage 
have not been met. Therefore, we decided that the Plan does not have to pay for the sedation services provided 
on October 9, 2019.