Persius/hicric huggingface dataset:
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the acute inpatient hospital care provided from March 6, 
2020, to March 10, 2020. 
 
You asked the Plan to pay for acute inpatient hospital care. You say that the services were medically necessary. 
The Plan denied your request. The Plan says inpatient services after March 5, 2020 were not medically 
necessary 
 
The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor 
expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases, 
consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or 
more.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pay for acute inpatient hospital care. Our reviewer 
says that the documentation does not support that the criteria for inpatient payment are met in this case. Our 
physician reviewer found review of progress notes do not outline advance treatments or critical interventions. 
The enrollee continued to receive intravenous antibiotics, but other medications were orally administered. The 
documentation does not support the need for inpatient level of care. Without the support of the documentation, 
medical necessity cannot be determined. Inpatient hospital care on March 6, 2020 and later is determined not 
medically necessary. The denial is upheld. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of acute inpatient hospital care have not been met. Therefore, we decided that the 
Plan does not have to pay for the acute inpatient hospital care provided from March 6, 2020, to March 10, 
2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a neuromuscular stimulator, electronic shock unit (CPT Code 
E0745) provided on April 26, 2020. 
 
You asked the Plan to pay for the neuromuscular stimulator. You say that the claim should be paid. The Plan 
denied your request. The Plan says experimental procedures are not covered under the member's plan. 
 
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 neuromuscular stimulator. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found this appeal considers the medical necessity of the requested neuromuscular 
stimulator, electronic shock unit (CPT Code E0745). The submitted documentation, Medicare guidelines, and 
Medicare approved compendia were considered. Review of the medical records does not include a detailed 
physical examination, imaging, or other detailed treatments trialed for the enrollee's condition. Without the 
support of the documentation, medical necessity cannot be determined. The denial is upheld. 
 
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 neuromuscular stimulator have not been met. Therefore, we decided that the 
Plan does not have to pay for a neuromuscular stimulator, electronic shock unit (CPT Code E0745) provided on 
April 26, 2020.
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 April 23, 2019. 
 
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 April 23, 2019.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the services (CPT 72100) provided on January 21, 2020. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says this is a duplicate 
billing. 
 
The Plan must follow Medicare rules. Medicare rules say that claims or claim lines that have been determined 
to be exact duplicates of another claim or claim line are denied.  
 
We looked at the file and Medicare rules. The services in question were billed on a duplicate claim to one 
previously processed and paid by the Plan. 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 (CPT 72100) provided on January 21, 2020.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for positron emission tomography provided on May 15, 2020. 
 
You asked the Plan to pay for the PET scan (78815). You say that the Plan should pay this claim. The Plan 
denied your request. The Plan says the reported diagnosis code is not acceptable. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate ICD-10 code. 
 
We find that ICD-10 code C7A.096 is not appropriate for this PET scan according to CMS. Based on this 
information, we decided that Medicare rules for coverage of the PET scan (78815) have not been met. 
Therefore, we decided that the Plan does not have to pay for positron emission tomography provided on May 
15, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for wound care provided on February 14, 2020 by an out of 
network (OON) provider. 
 
You asked the Plan to pay for wound care. You say that you would like this claim reprocessed and approved 
for payment. The Plan denied your request. The Plan says the referring provider is out-of-network. The Plan 
says that prior authorization was 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 wound care provided on February 14, 2020 by an 
out of network (OON) provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the skilled home healthcare services provided May 20, 2020 
to May 28, 2020 
 
You asked the Plan to pay for the skilled home healthcare services. You say that the claim was billed with type 
of bill 0322 which is an Interim First Interim claim for per visit claims. Please reprocess the claim as per visit 
and not episodic for these dates of service. The Plan denied your request. The Plan says the claim was billed 
with an invalid HIPPS rate code. A corrected claim must be submitted. 
 
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 G0151, G0299 and A9999 is  home health physical 
therapy services,  home health skilled nursing services and miscellaneous DME supply or accessory. 
 
We find that CPT code G0151 is not supported in the medical record. Specifically, the claim was billed with an 
invalid HIPPS code. A corrected claim must be submitted. Based on this information, we decided that 
Medicare rules for coverage of the skilled home healthcare services have not been met. Therefore, we decided 
that the Plan does not have to pay for the skilled home healthcare services provided May 20, 2020 to May 28, 
2020
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the psychotherapy office visit. 
 
You asked the Plan to pay for the psychotherapy office visit. You say that you have been seeing this doctor for 
the last 20 years and have never had a claim turned down. You were unaware that the doctor does not 
participate with Medicare and that the plan will not pay. The Plan denied your request. The Plan says if you go 
to a provider who is not eligible to participate in Medicare, you will be responsible for the full cost of the 
services you receive. 
 
The 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 the provider. This 
provider has opted out of the Medicare program. Therefore, we decided that the Plan does not have to pay for 
the psychotherapy office visit.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the problem focused limited oral evaluation (D0140) 
provided on May 27, 2020. 
 
You asked the Plan to pay for the problem focused limited oral evaluation. You say that at your appointment in 
March, you were told that the provider does not accept Medicare insurance. You also say that you were told 
that there would be no charge for the evaluation. The Plan denied your request. The Plan says this service 
exceeds the frequency limitation in 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, problem focused limited oral 
evaluation (D0140) is limited to one procedure per plan year. The record shows that you received a problem 
focused limited oral evaluation (D0140) on March 9, 2020, and your problem focused limited oral evaluation 
(D0140) benefit has been exhausted. Therefore, we decided that the Plan does not have to pay for the problem 
focused limited oral evaluation (D0140) provided on May 27, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the chiropractic services provided on May 13, 2020. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says these services are not 
covered. 
 
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.  
 
The records show that the services at issue are not manual manipulation of the spine. Therefore, we decided 
that the Plan does not have to pay for the chiropractic services provided on May 13, 2020.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for laboratory testing provided on November 28, 2019. 
 
You asked the Plan to pay for lab tests. You say that you are appealing with records. The Plan denied your 
request. The Plan says the denial of payment for these services is correct, because the documentation submitted 
does not support the coding of this claim. 
 
The Plan must follow Medicare rules. Medicare rules say that if an independent lab bills for services, the place 
where the sample was taken is reported as the Place of Service (POS).  
 
We looked at the file and Medicare rules. This claim was billed with Place of Service (POS) code 81 ? 
indicating an independent laboratory setting ? however the documentation submitted does not support that the 
sample for testing was taken in an independent laboratory setting. Based on this information, we decided that 
Medicare rules for coverage of lab tests have not been met. Therefore, we decided that the Plan does not have 
to pay for laboratory testing provided on November 28, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the advance care planning rendered on February 3, 2020. 
 
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says procedure code 99497 is not separately payable. 
 
The rules say that, for edits with a modifier indicator of 1, the Column 2 code is payable only if a clinically 
appropriate NCCI modifier is used to report the reason it should be paid as well. 
 
The provider submitted a claim for procedure codes 99497 and 99223. Code 99497 is a column II code with a 
modifier indicator of 1 when billed with column I code 99223. Code 99497 was not billed with an appropriate 
modifier to allow for separate payment. Therefore, we decided that the Plan does not have to pay for the 
advance care planning rendered on February 3, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay forthe medical services provided to the enrollee by an out-of-network provider on January 28, 2020.You asked the Plan to pay forthe 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 forthe medical services provided to the enrollee by an out-of-network provider on January 28, 2020.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the diagnostic breast tomosynthesis rendered on May 7, 
2020. 
 
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says the services are not covered. 
 
The Plan must follow Medicare rules. The rules say that a status indicator of I represents a code that is not valid 
for Medicare purposes.  
 
We looked at the file and Medicare rules. The provider billed procedure code 77062. This code has a status 
indicator of I and is not valid for Medicare purposes. Therefore, we decided that the Plan does not have to pay 
for the diagnostic breast tomosynthesis rendered on May 7, 2020.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to reimburse you for surgery provided on February 27, 2020. 
 
You asked the Plan to reimburse you for the surgery. 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 
surgery 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 reimburse you for surgery provided on February 27, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the anesthesia services rendered on January 24, 2020. 
 
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says the services are not covered. 
 
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 01996 is 1. You billed 8 units of this code, exceeding the MUE. Based on 
this information, we decided that Medicare rules for coverage of these services have not been met. Therefore, 
we decided that the Plan does not have to pay for the anesthesia services rendered on January 24, 2020.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ambulance services provided on September 4, 2020. 
 
You asked the Plan to pay for the ambulance services. You say that you did not call the ambulance. You are 
elderly and this charge is excessive for your living expenses. The Plan denied your request. The Plan says these 
services are not a covered benefit. 
 
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 September 4, 2019. 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 September 4, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for physician services provided on March 27, 2020 by an out of network (OON) provider.You asked the Plan to pay forskilled nursing services. You say that these services were provided at a nursing facility. You say that you would like these claim reprocessed and approved for payment.The Plan denied your request. The Plan says prior authorization was not obtained by the facility or the 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 forphysician services provided on March 27, 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 subsequent nursing facility care, per day (99309) rendered by 
the out of network (OON) provider on June 16, 2020. 
 
You asked the Plan to pay for this service. You say that you are requesting a reconsideration of the Plan's 
denial for payment. The Plan denied your request. The Plan says the service was rendered by an out of network 
provider, without prior authorization. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The provider in this case is not a network provider with the Plan. The Plan has network providers available 
who can provide the service at issue in this appeal. The Plan did not pre-approve the service at issue. We found 
no exception that would require the Plan to pay for this service. Therefore, we decided that the Plan does not 
have to pay for subsequent nursing facility care, per day (99309) rendered by the out of network (OON) 
provider on June 16, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay forhospital discharge day management services (99239) provided on November 18, 2019.You asked the Plan to pay forthe hospital discharge day management services. You say that you would like reconsideration based on the records submitted.The Plan denied yourrequest. The Plan says the submitted discharge summary does not support hospital discharge day management of more than 30 minutes was performed.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 99239 is hospital discharge day management; more than 30 minutes. We find that CPT code 99239 is not supported in the medical record. Specifically, the record does not indicate that 30 minutes of hospital discharge day management services were rendered. Based on this information, we decided that Medicare rules for coverage of the hospital discharge day management services have not been met.Therefore, we decided that the Plan does not have to pay forhospital discharge day management services (99239) provided on November 18, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the consultation (D9310) and cone beam CT capture and 
interpretation (D0364) provided on March 5, 2020. 
 
You asked the Plan to pay for the consultation and cone beam CT capture and interpretation. You say that you 
signed up for dental benefits in January 2020, and were told that you would have dental coverage. You also say 
that you are on a limited income. The Plan denied your request. The Plan says these services are not covered 
benefits under your dental 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 
consultation (D9310) and cone beam CT capture and interpretation (D0364) provided on March 5, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the orthotics rendered on April 2, 2020. 
 
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says there is no valid proof of delivery. 
 
The Plan must follow Medicare rules. The Plan must follow Medicare rules. The rules say that all DMEPOS 
suppliers are required to maintain proof of delivery. 
 
We looked at the file and Medicare rules. There is no valid proof of delivery in the documentation. Based on 
this information, we decided that Medicare rules for coverage of these services have not been met. Therefore, 
we decided that the Plan does not have to pay for the orthotics rendered on April 2, 2020.