Persius/hicric huggingface dataset:
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a segmented pneumatic compression device for the enrollee.

You asked the Plan to pre-approve the device. You say that this is medically necessary.The Plan denied your request. The Plan says there is no documentation of a trial and failure of a four-week good-faith trial with a basic pump.

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 device. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found based on the medical records provided, there is no documentation that the enrollee has unique characteristics that would indicate the segmental pump over a standard pump. There is no documentation that there has been an adequate trial and failure of the standard pump.


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 device have not been met.Therefore, we decided that the Plan does not havexto pre-approve a segmented pneumatic compression device for the enrollee.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay forthe transportation of a portable x-ray (R0070) provided on May 28, 2020.You asked the Plan to pay forthe transportation of a portable x-ray. You say that you would like reconsideration based on the records submitted.The Plan denied your request. The Plan says CPT code R0070 is a technical component only code and it should be reported on a hospital setting.The Plan must follow Medicare rules. Medicare rules say that the technical component representing the procedure itself, including any associated transportation and setup costs, would be subject to consolidated billing, and must be included on the SNF's Part A bill for the resident's covered stay rather than being billed separately under Part B.We find that CPT code R0070 is not supported in the record. Specifically, this claim was billed with place of service code 31, indicating that they were in a Part A covered SNF stay. The service billed is subject to consolidated billing and is included in the SNFs Part A bill. Payment for this service is the responsibility of the facility to any vendor. Based on this information, we decided that Medicare rules for coverage of the transportation of a portable x-ray have not been met.Therefore, we decided that the Plan does not have to pay forthe transportation of a portable x-ray (R0070) provided on May 28, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the services (69220) provided on July 16, 2020.
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the MUE value for this code is "1".
The Plan must follow Medicare rules. Medicare rules say that claims submitted where the unit of service exceeds the MUE value for the HCPCS/CPT code will be denied. In this case, the MUE for CPT code 69220 is 1. You billed 2 units of this code, exceeding the MUE. 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 (69220) provided on July 16, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the scaling in presence of generalized moderate or severe
gingival inflammation and preventive procedure provided on August 19, 2020.
You asked the Plan to pay for the scaling and preventive procedure. You say that you should only be billed
$155.00, but received a bill for $395.00 for these services that were not covered by your insurance. The Plan
denied your request. The Plan says these services are 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
scaling in presence of generalized moderate or severe gingival inflammation and preventive procedure
provided on August 19, 2020.
Appeal type: DME/ Orthotics
Decision: Favorable

We decided that the Plan has to pay fora thoracic lumbar-sacral orthosis (L0457) provided on July 16, 2020.You asked the Plan to pay fororthosis. You say that no patient should be denied care or pain management solutions because they are required to have certain historical documentation.The Plan denied your request. The Plan says that the denial of payment for this item is correct, because the documentation submitted does not include a face-to-face encounter with the ordering physician.The Plan must follow Medicare rules. Medicare rules say that thoracic lumbar-sacral orthosis L0457 has not been selected as an item that is subject to face-to-face encounter requirements prior to ordering. We looked at the file and Medicare rules. The Plan has denied payment on the basis that this item did not meet face-to-face encounter requirements. However, this item is not subject to face-to-face encounter requirements according to Medicare rules. The documentation submitted meets the documentation requirements for this specific item. Based on this information, we decided that Medicare rules for coverage of orthosis have been met.Therefore, we decided that the Plan has to pay fora thoracic lumbar-sacral orthosis (L0457) provided on July 16, 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: 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 May 7, 2020. You asked the Plan to pay for the services. The Plan denied your request. The Plan says the services were not approved in advance. 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 May 7, 2020.
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to pay forthe emergency department visit (99285) provided on July 14, 2020.You asked the Plan to pay forthe emergency department visit. You say that you would like reconsideration because the services rendered were medically necessary.The Plan denied your request. The Plan says the diagnosis code to not match the service billed.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 find that CPT code 99285 is not supported in the record. Specifically, the record indicates that the member had tested positive for COVID19, was feelingbetter and requested a test to see if the virus was out of his system. The record does not indicate that the member's presenting problems were of high severity or posed an immediate significant threat to life of physiologic function. There is a more appropriate code for the services rendered. Based on this information, we decided that Medicare rules for coverage of the emergency department visit have not been met.Therefore, we decided that the Plan does not have to pay forthe emergency department visit (99285) provided on July 14, 2020
Appeal type: Imaging
Decision: Favorable

We decided that the Plan has to pay forthe chest x-ray (71045) provided on June 5, 2020.You asked the Plan to pay forthe chest x-ray. You say that you would like reconsideration because this claim was denied as a duplicate in error.The Plan denied your request. The Plan says that CPT code 71045 is a column II code to CPT code 77001.The Plan must follow Medicare rules. Medicare rules say that MACs subject all line items for the same beneficiary, same NPI, and same date of service to NCCI edits.We find that CPT code 71045 is supported in the record. Specifically, the record indicates that the column I code was billed by a provider with a different NPI. It is not appropriate to apply NCCI edits to line items with different NPIs. Based on this information, we decided that Medicare rules for coverage of the chest x-ray have been met.Therefore, we decided that the Plan has to pay forthe chest x-ray (71045) provided on June 5, 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: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for nuclear medicine provided on October 1, 2019 by an out of
network (OON) provider.
You asked the Plan to pay for nuclear medicine. You say that this test was ordered by a doctor. You say that it
should have been the doctor's responsibility to get the OK from the Plan. The Plan denied your request. The
Plan says prior authorization was not obtained. The Plan says that there are in-network providers available for
these services.
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 nuclear medicine provided on October 1, 2019 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 fordiagnostic mammography, including computer-aided detection (CAD) when performed; unilateral (77066) provided July 31, 2020.You asked the Plan to waive the copayment forthe mammography. You say that You have been doing this procedure for four years at the same place and facility. You have never received any bill like this and all of a sudden you have to pay copayments.The Plan denied your request. The Plan says the claim was processed and the correct copayment was 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 $80 copayment for diagnostic mammography in an outpatient hospital.You have been asked to pay $80 copayment for the mammography. The mammography falls within the Outpatient diagnostic tests and therapeutic services and supplies 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 fordiagnostic mammography, including computer-aided detection (CAD) when performed; unilateral (77066) provided July 31, 2020
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pay for the subsequent nursing facility care provided on March 3,
2020 by an OON provider.
You asked the Plan to pay for the subsequent nursing facility care. You say that the treating physician depends
upon the hospital staff to verify eligibility and to obtain the proper authorization for in-network and OON
providers from the enrollee's insurance company. You also say that the facility failed to obtain the necessary
authorization for this enrollee. The Plan denied your request. The Plan says these services were rendered by a
non-contracted provider, and prior authorization was not obtained.
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 subsequent nursing facility care provided on
March 3, 2020 by an OON provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for specialist services by an out of network (OON) provider.

You asked the Plan to pay for specialist services. You say that you would like this claim reprocessed and approved for payment.The Plan denied your request. The Plan says prior authorization was not obtained. The Plan says that the member's primary care physician did not refer these services.

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.T

he 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 specialist services provided by an out of network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to reimburse you for the IV infusions provided from February 4, 2020,
to February 18, 2020.
You asked the Plan to reimburse you for the IV infusions. You say that the Plan should reimburse you for the
infusions. The Plan denied your request. The Plan says the IV infusions services are considered investigational
and experimental for your diagnosis.
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically
necessary are not covered.
We looked at the file and Medicare rules. This drug is not FDA approved for Major Depressive Disorder.
Based on this information, we decided that Medicare rules for coverage of the IV infusions have not been met.
Therefore, we decided that the Plan does not have to reimburse you for the IV infusions provided from
February 4, 2020, to February 18, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for physician's services provided on September 9, 2020.
You asked the Plan to pay for the physician's 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 physician's 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 September 9, 2020.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pay for home infusion therapy (S9328) provided on April 30, 2020,
to June 4, 2020.
You asked the Plan to pay for home infusion therapy. You say that the enrollee was referred for these services
by an in-network provider. The Plan denied your request. The Plan says these services were not billed with a
valid code.
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 S9328 is not supported in the medical record. Specifically, this code has a status
indicator of "I." Medicare uses another code for reporting of, and payment for these services. Based on this
information, we decided that Medicare rules for coverage of home infusion therapy have not been met.
Therefore, we decided that the Plan does not have to pay for home infusion therapy (S9328) provided on April
30, 2020, to June 4, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay forthe office visit (99213) provided on February 12, 2020 by an out of network (OON) provider.You asked the Plan to pay foran OON office visit. You say that this should be covered at the same rate as in-network services.The Plan denied your request. The Plan says this was not authorized.Medicare rules say that plans can require enrollees toget 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 forthe office visit (99213) provided on February 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 physician's services provided on September 1, 2020. You asked the Plan to pay for the physician's 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 physician's 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 September 1, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for orthotics (L2397, L1833) provided on July 15, 2020.
You asked the Plan to pay for orthotics. You say that these items were necessary. The Plan denied your request. The Plan says there is not an appropriate face-to-face encounter related to these items.
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 orthotics (L2397, L1833) provided on July 15, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for progressive lens, per lens (V2781) provided on July 9, 2020.
You asked the Plan to pay for progressive lens. You say that the service should be covered. The Plan denied your request. The Plan says one pair of eyeglasses (or contact lenses) are covered for people after cataract surgery. Review of the enrollee's past claims confirms that the enrollee never had cataract surgery, therefore he does not have any coverage for eyeglass expenses.
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 one routine eye exam per calendar year and only covers eyeglasses after cataract surgery. We looked at the file and the Plan's rules. The item is not a covered benefit. Based on this information, we decided that the Plan's rules for coverage of progressive lens have not been met. Therefore, we decided that the Plan does not have to pay for progressive lens, per lens (V2781) provided on July 9, 2020.