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

 
We decided that the Plan does not have to pay for chiropractic services provided to the enrollee on July 3, 
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 benefit coverage cannot be provided for the chiropractic services. 
 
The Plan must follow Medicare rules. The rules say that the only chiropractic service Medicare covers is 
manual manipulation of the spine to correct a subluxation.  
 
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 reviewer says that the 
services at issue in this case were not supported by the medical records. Our physician reviewer found the only 
treatment allowed by Medicare for chiropractors is to treat a subluxation of the spine. The subluxation may be 
demonstrated by x-ray or by physical examination. The submitted chart note/office visit of 7/3/20, the date of 
service in question, reveals that the enrollee jammed her back in the bathtub, a finding of temperature of 98.1 F, 
manipulation rendered and plan of two times next week. Diagnoses throughout include other idiopathic 
scoliosis and/or segmental and somatic dysfunctions of the lumbar, sacrum and thoracic regions. Other office 
visit notes include 7/7/20, 7/11/20, 7/18/20, 7/24/20 and 7/28/20, with the only finding of temperature on 
7/18/20, 7/24/20 and 7/28/20. These findings do not reveal evidence of subluxation per Medicare guidelines. 
Thus, chiropractic treatment is neither supported nor allowed per Medicare guidelines. 
 
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 chiropractic services provided to the enrollee on July 3, 2020.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the ultrasound provided on August 6, 2020. 
 
You asked the Plan to waive the copayment for the ultrasound. You say that there is no way you can afford to 
pay the high cost. The Plan denied your request. The Plan says the copayment applied correctly. 
 
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 $155 
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 $144.26, which is less than the standard $155 copayment for the ultrasound. The 
ultrasound 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 for the ultrasound provided on August 6, 2020.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pay for services, S9502 and S9500, provided to the enrollee. 
 
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 these codes cannot be paid due to their status 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. In this the codes billed have a status code of I 
which excludes payment for these codes under Medicare. Medicare uses another type of codes for these 
services. Medicare billing criteria are not met. Therefore, we decided that the Plan does not have to pay for 
services, S9502 and S9500, provided to the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the knee x-ray services coded 73560 provided. 
 
You asked the Plan to pay for the knee x-ray 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 73560 is radiologic examination, knee; 1 or 2 views. 
 
We find that CPT code 73560 is not supported in the medical record. Specifically, this code was billed without 
an anatomic specific modifier. An anatomic specific modifier LT (left side), RT (right side), or 50 (bilateral) is 
required to be billed with this procedure. Based on this information, we decided that Medicare rules for 
coverage of the knee x-ray services have not been met. Therefore, we decided that the Plan does not have to 
pay for the knee x-ray services coded 73560 provided.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the Dexcom G5-G4 sensor 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 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 services. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found the documentation notes the enrollee checks blood glucose levels twice a day. The referenced guideline 
outlines an indication that the beneficiary has been using a BGM and performing frequent (four or more times a 
day) testing. Documentation does not support the guidelines have been met. Medical necessity cannot be 
determined. 
 
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 the Dexcom G5-G4 sensor for the enrollee.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for intermittent limb compression device. 
 
You asked the Plan to pay for intermittent limb compression device. You say that the enrollee requires the 
device. The Plan denied your request. The Plan says the documentation failed to prove that sufficient evidence 
of four-week trial of conservative therapy. 
 
The Plan follows Medicare rules. The rules state that a PCD coded as E0651 is covered for the treatment of 
lymphedema and/ or for the treatment of chronic venous insufficiency with venous stasis ulcers. A four-week 
trial of conservative therapy demonstrating failed response to treatment is required. 
 
 
 
We looked at the file and Medicare rules. Based on this information we decided that Medicare rules for 
coverage of the PCD have not been met. Specifically, the record does not show that the enrollee had at least 
four weeks of regular home usage of conservative therapy including compression garments, exercise and 
elevation. Therefore, we decided that the Plan does not have to pay for intermittent limb compression device.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for outpatient hospital services provided July 
28, 2020. 
 
You asked the Plan to waive the coinsurance for the outpatient hospital services. You say that the coinsurance 
should be waived. The Plan denied your request. The Plan says the correct cost-sharing 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 a 20% 
coinsurance for Outpatient Hospital Services.  
 
You have been asked to pay a 20% coinsurance for the outpatient hospital services. 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 coinsurance for outpatient hospital services provided July 28, 2020.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pay for the home infusion services provided on August 20, 2020, 
billed with codes 99601 and 99602. 
 
You asked the Plan to pay for the home infusion services. You say that this should be covered. The Plan denied 
your request. The Plan says this was not billed with valid 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. 
 
Codes 99601 and 99602 have a status indicator of "I" in the Physician Fee Schedule meaning that they are 
invalid for Medicare billing purposes. Based on this information, we decided that Medicare rules for coverage 
of the home infusion services have not been met. Therefore, we decided that the Plan does not have to pay for 
the home infusion services provided on August 20, 2020, billed with codes 99601 and 99602.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for a dental abutment (D6057) and crown (D6058) received on 
June 10, 2020. 
 
You asked the Plan to pay for a dental abutment and crown. You say that since this is a dental procedure 
Medicare should not be a factor. The Plan denied your request. The Plan says the provider has opted out of 
Medicare. 
 
The Plan must follow Medicare rules. The rules say that no Medicare payment may be made to a beneficiary 
for items or services provided directly by a physician or practitioner who has opted out of the program except 
in cases involving emergencies or urgently needed care. 
 
The services at issue in this appeal were provided in a non-urgent, non-emergent situation by a provider who 
has opted out of the Medicare program. Therefore, we decided that the Plan does not have to pay for a dental 
abutment (D6057) and crown (D6058) received on June 10, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the medical services provided on May 28, 2020 by an out of 
network (OON) provider. 
 
You asked the Plan to pay for the medical services. You say that you would like the Plan to reconsider their 
denial of payment. The Plan denied your request. The Plan says the services provided were neither emergent 
nor urgent and prior authorization was not obtained to provide 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 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 May 28, 2020 by 
an out of network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the dental services provided on May 27, 2020 by an out of 
network (OON) provider. 
 
You asked the Plan to pay for the dental services. You say that you would like the Plan to reconsider their 
denial of payment. The Plan denied your request. The Plan says the services received were neither emergent 
nor urgent to seek out-of-network care. The Plan says that your contract clearly says you would be responsible 
for 100% of the charges for dental services provided 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 dental services provided on May 27, 2020 by 
an out of network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a scooter. 
 
You asked the Plan to pay for the scooter. You say that the claim should be paid, you do not feel you should 
have to go in to the doctor due to COVID-19. The Plan denied your request. The Plan says the request for a 
power scooter must include a face-to-face evaluation provided by a qualified health professional and physicians 
order. 
 
The rules say for Medicare to consider coverage and payment for any item or service, the information 
submitted by the supplier or provider must corroborate the documentation in the beneficiary's medical 
documentation and confirm that Medicare coverage criteria have been met. When conducting a review of a 
covered DME item, ordered by a physician, the contractor shall ensure that the physician saw the beneficiary 
and conducted a face-to-face assessment.  
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the durable medical equipment have not been met. Specifically, medical records do not support a 
prior face-to-face examination with the ordering physician within 6 months of ordering the DME or an 
appropriate use of telehealth. The submitted consultation notes do not support that a physical examination 
 
 
regarding the scooter was performed. The information submitted does not confirm that Medicare coverage 
criteria have been met. 
  
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 a scooter.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the specimen collection travel allowance billed for testing 
provided on September 6, 2019 billed with code P9604. 
 
You asked the Plan to pay for the travel allowance. You say that these services should be paid due to medical 
necessity. The Plan denied your request. The Plan says the records do not support the billing of the travel 
allowance. 
 
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 P9604 is Travel allowance one way in connection with 
medically necessary laboratory specimen collection drawn from home bound or nursing home bound patient; 
prorated trip charge. 
 
We find that CPT code P9604 is not supported in the medical record. Specifically, there is no documentation to 
support that this specimen required any travel to obtain. Based on this information, we decided that Medicare 
rules for coverage of the travel allowance have not been met. Therefore, we decided that the Plan does not have 
to pay for the specimen collection travel allowance billed for testing provided on September 6, 2019 billed with 
code P9604.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approvelong term acute care hospital (LTACH) services.You asked the Plan to pre-approvethe LTACH services. You say that the services are necessary.The Plan denied your request. The Plan says based on the documentation provided, coverage criteria has not been met.The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee.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 LTACH services. Our reviewer says that the requested LTACH care is not considered medically reasonable and necessary in this case. Our physician reviewer found the documentation does not support that the enrollee in this case requires services at the LTACH that are not available at the acute care hospital where they are currently receiving care. There are no required medical services identified that are available at the LTACH, that are not available at the current health care setting being offered by the health plan. Consequently, the requested LTACH services are not medically necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee 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 LTACH services have not been met.Therefore, we decided that the Plandoes not have to pre-approvelong term acute care hospital (LTACH) services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for a knee orthosis provided to the enrollee on August 20, 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 documentation submitted did not indicate that the provider discussed the need for the billed 
supply 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. 
 
In this case, the CPT Code Manual definition of HCPCS code L1833 is "Knee orthosis, adjustable knee joints 
(unicentric or polycentric), positional orthosis, rigid support, prefabricated, off-the shelf." 
 
We asked our coding reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pay for the services. Our reviewer says that the 
services at issue in this case were not supported by the medical records. Our coding reviewer found the medical 
records provided do not include documentation that complies with Medicare rules regarding meeting coverage 
criteria of Durable Medical Equipment, therefore this service cannot be verified and is not eligible for 
reimbursement consideration. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the services have not been met. Therefore, we decided that the Plan does not 
have to pay for a knee orthosis provided to the enrollee on August 20, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the topical application of fluoride (D1208) and 3 fillings 
(D2330) provided from August 20, 2020, to August 25, 2020. 
 
You asked the Plan to pay for the fluoride and 1 filling. You say that you were advised by a plan representative 
that your dentist was in network and the services would be covered. You say that now you have a bill that says 
your services were denied because the dentist was out of network. The Plan denied your request. The Plan says 
the topical application of fluoride is not listed as a covered service. The Plan says that 2 fillings per calendar 
year are covered. The Plan also says that the frequency limit has been exceeded. 
 
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 topical application of fluoride is 
not among those covered under this benefit. Additionally, the frequency limit of 2 fillings per calendar year has 
been exceeded. The record shows that the Plan paid for 2 of the fillings that you received on the date of service 
in this case, thus exceeding the limit. Therefore, we decided that the Plan does not have to pay for the topical 
application of fluoride (D1208) and 3 fillings (D2330) provided from August 20, 2020, to August 25, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve localized delivery of antimicrobial agents for teeth #15, 18, and 2 (D4381).
You asked the Plan to pre-approve localized delivery of antimicrobial agents for teeth #15, 18, and 2. You say that the services are necessary. The Plan denied your request. The Plan says the requested services are not a covered benefit.
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 pre-approve localized delivery of antimicrobial agents for teeth #15, 18, and 2 (D4381).
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the colonoscopy provided on August 20, 
2020. 
 
You asked the Plan to waive the copayment for the colonoscopy. You say that you had this three years ago and 
didn't pay anything. The Plan denied your request. The Plan says the copayment applied correctly. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $150 
copayment for Medicare-covered outpatient surgery in an ambulatory surgical center or hospital outpatient 
facility.  
 
You have been asked to pay a $150 copayment for the colonoscopy. The colonoscopy falls within the 
"Outpatient surgery, including services provided at hospital outpatient facilities and ambulatory surgical 
centers" benefit category. The records show that eight polyps were removed during the colonoscopy, which is 
considered a surgical procedure. 
  
 
 
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 colonoscopy provided on August 20, 2020.