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

We decided that the Plan does not have to pay for critical care service provided on November 12, 2019. 
 
You asked the Plan to pay for critical care. You say that you are appealing. The Plan denied your request. The 
Plan says the denial of payment for this service is correct, because the documentation submitted does not 
include the time spent providing this service to support the code 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 99291 is critical care, evaluation and management of the 
critically ill or critically injured patient; first 30 to 74 minutes. 
 
We find that CPT code 99291 is not supported in the medical record. Specifically, the documentation does not 
show that this critical care service lasted 30 to 74 minutes in duration. Based on this information, we decided 
that Medicare rules for coverage of critical care have not been met. Therefore, we decided that the Plan does 
not have to pay for critical care service provided on November 12, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the critical care services provided from September 9, 2019, 
to September 15, 2019. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the billed services 
cannot be verified. 
 
The Plan must follow Medicare rules. The rules say that critical care is not a service that is paid on a shift 
basis or a per day basis. Critical care service is paid on a time-based service provided on an hourly or fraction 
of an hour basis. For this reason, the documentation provided by the physician must include the amount of time 
in hours and minutes that is spent on providing critical care service. In this case, there is no evidence in the 
medical documentation to show the total time spent delivering critical care to the enrollee. Therefore, we 
decided that the Plan does not have to pay for the critical care services provided from September 9, 2019 to 
September 15, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for durable medical equipment provided to the enrollee on May 
16, 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 Healthcare Common Procedure Coding System (HCPCS) code A4253 NU 99 KS KL (2 Units) 
remains not supported. 
 
The Plan must follow Medicare rules. Providers must report services with the appropriate CPT code. Medicare 
rules say that DME supplies must be provided with a proof of delivery. 
 
The required documentation pertaining to the proof of delivery of these supplies was not provided. 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 durable medical equipment provided to the enrollee on May 16, 
2020.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the computed tomography (CT) scan of the 
thorax (71260) provided on July 6, 2020. 
 
You asked the Plan to waive the copayment. You say that you are requesting a reconsideration of the Plan's 
denial for payment. The Plan denied your request. The Plan says the copayment has been applied correctly to 
the service 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 $180 
copayment for advanced imaging services rendered by an in-network provider.  
 
You have been asked to pay a $168 copayment for the advanced imaging service rendered by an in-network 
provider. This is the Plan allowed amount which is less than the applicable copayment. 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 computed tomography (CT) scan of the thorax (71260) provided 
on July 6, 2020.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a specialist office visit provided on July 14, 2020 by an out 
of network (OON) provider. 
 
You asked the Plan to pay for a specialist office visit. 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 these services could have been provided in-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 a specialist office visit provided on July 14, 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 automatic external defibrillator (CPT Code K0606) provided 
on March 19, 2020. 
 
You asked the Plan to pay for the DME. You say that the member cannot receive the services from an in-
network provider. The Plan denied your request. The Plan says the member was inpatient from March 17, 
2020, through March 20, 2020. 
 
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must be appropriate 
and needed for use inside the home. Medicare does not consider a SNF or a hospital to be a home.  
 
Records show that the DME was used in a SNF or hospital. Therefore, we decided that the Plan does not have 
to pay for automatic external defibrillator (CPT Code K0606) provided on March 19, 2020.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the lab services provided on January 14, 2020. 
 
You asked the Plan to pay for the lab services. The Plan denied your request. The Plan says the services were 
billed with the incorrect place of service. 
 
The Plan must follow Medicare rules. Medicare rules say that the POS code to be used by the physician or 
other supplier will be assigned as the same setting in which the beneficiary received the face-to-face service.  
 
We looked at the file and Medicare rules. The documentation shows that the services in question were billed 
with POS code 81. However, the records indicate that the specimen was collected in an office setting, which 
would be indicated by POS code 11. This means that the claim was billed with the incorrect POS code. Based 
on this information, we decided that Medicare rules for coverage of the lab services have not been met. 
Therefore, we decided that the Plan does not have to pay for the lab services provided on January 14, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the continuous passive motion device provided from January 
27, 2020, to February 16, 2020. 
 
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. The rules say that CPM devices are covered only if use of the device 
began within two days of receiving total knee replacement surgery.  
 
Records show that total knee replacement surgery was received on December 16, 2019. Use of a CPM device 
did not begin until January 27, 2020. This means that use of a CPM device did not start until more than two 
days had elapsed following total knee replacement surgery. Therefore, we decided that the Plan does not have 
to pay for the continuous passive motion device provided from January 27, 2020, to February 16, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for a lumbar-sacral orthosis (L0648) provided to the enrollee on 
June 12, 2020. 
 
You asked the Plan to pay for the orthosis. You say that the claim should be paid. The Plan denied your 
request. The Plan says the documentation submitted did not include an itemized shipping/billing invoice to 
indicate the specific supplies, or valid proof of delivery with order number for the billed date of service. 
 
The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when there are both a 
physician order and proof of delivery.  
 
The record does not contain the valid the documentation required to verify the appeal. The documentation 
submitted did not include an itemized shipping/billing invoice to indicate the specific supplies, or valid proof of 
delivery with order number for the billed date of service.  The record shows that the Plan made several attempts 
to obtain the necessary documentation without success. Therefore, we decided that the Plan does not have to 
pay for a lumbar-sacral orthosis (L0648) provided to the enrollee on June 12, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay foroutpatient services provided on August 4, 2020 by an out of network (OON) provider.You asked the Plan to pay foroutpatient services. You say that you would like this appeal reprocessed and approved for payment.The Plan denied your request. The Plan says prior authorization was not obtain. 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 thePlan does not have to pay foroutpatient services provided on August 4, 2020 by an out of network (OON) provider.
Appeal type: Hospice
Decision: Unfavorable

 
We decided that the Plan does not have to pay for subsequent nursing facility care (99309) provided on May 
14, 2020. 
 
You asked the Plan to pay for nursing facility care. You say that the services rendered were medically 
necessary. The Plan denied your request. The Plan says the member's claim would be covered under Original 
Medicare as it is responsible for coverage of Part B benefits starting on the date of election until the last day of 
the month in which hospice is revoked. 
 
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 subsequent nursing facility care (99309) provided on May 14, 
2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for outpatient hospital services provided on June 26, 2020 by an 
out of network (OON) provider. 
 
You asked the Plan to pay for outpatient hospital 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 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 outpatient hospital services provided on June 26, 
2020 by an out of network (OON) provider.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for home health services provided to the enrollee from January 
1, 2020 to February 5, 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 there is an invalid HIPPS code. 
 
The Plan must follow Medicare rules. Medicare rules say that home health services must be reported correctly. 
 
The HIPPS code is invalid for 2020. 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 home health 
services provided to the enrollee from January 1, 2020 to February 5, 2020.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home infusion therapy rendered on February 28, 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 that home infusion services and supplies may be 
covered as a supplemental benefit. Home infusion therapy supplies are not covered by Original Medicare. The 
Plan does not include a mandatory supplemental benefit for home infusion therapy services or supplies. 
 
We looked at the file and Medicare and the Plan's rules. Based on this information, we decided that Medicare 
and the Plan's rules for coverage of these services have not been met. Therefore, we decided that the Plan does 
not have to pay for the home infusion therapy rendered on February 28, 2020.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for genetic testing provided on November 29, 2019. 
 
You asked the Plan to pay for genetic testing. 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 these tests were ordered 
by telemedicine which is a Medicare prohibited action. 
 
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 genetic testing provided on 
November 29, 2019.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the medical services provided on May 22, 2020 to June 16, 
2020 by an out of network (OON) provider. 
 
You asked the Plan to pay for outpatient services and tests. You say that you were not aware that these 
providers were out-of-network. The Plan denied your request. The Plan says the denial of payment for these 
services is correct, because these providers are out-of-network with the Plan and the Plan did not authorize 
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 the medical services provided on May 22, 2020 to 
June 16, 2020 by an out of network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay forthe Comprehensive Genomic Profile (CGP) testing provided on May 18, 2020.You asked the Plan to pay forthe CGP testing. You say that you would like the Plan to reconsider their denial ofpayment.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.We find that the various denied CPT codes are not supported in the medical record. Specifically, the testing at issue in this case should be reported with CPT 81479. Based on this information, we decided that Medicare rules for coverage of the CGP testing have not been met.Therefore, we decided that the Plan does not have to pay forthe Comprehensive Genomic Profile (CGP) testing provided on May 18, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to issue reimbursement for the seat lift mechanism (E0627) and the 
sales tax (S9999) provided on June 2, 2020. 
 
You asked the Plan to issue reimbursement. You say that you are requesting a reconsideration of the Plan's 
denial for payment. The Plan denied your request. The Plan says that the seat lift mechanism is not a covered 
benefit as it was purchased from a provider that does not participate in the Medicare program. 
 
The Plan must follow Medicare rules. Medicare rules say that no provider or supplier shall receive payment for 
services furnished to a Medicare beneficiary unless the provider or supplier is enrolled in the Medicare 
program. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the seat lift mechanism have not been met. Specifically, this item was purchased from a provider 
that does not participate in the Medicare program. Therefore, we decided that the Plan does not have to issue 
reimbursement for the seat lift mechanism (E0627) and the sales tax (S9999) provided on June 2, 2020.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Hydrocodone-Acetaminophen tablets. 
 
You asked the Plan to pre-approve Hydrocodone-Acetaminophen tablets. You say that you would like the Plan 
to reconsider their denial. The Plan denied your request. The Plan says Hydrocodone-Acetaminophen tablets 
are not covered under the enrollee's Medicare Part B benefit. 
 
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-
administered drugs. The self-administered drugs requested here are not among the types which are covered by 
Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve Hydrocodone-
Acetaminophen tablets.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a specialist office visit (99213) on July 10, 
2020. 
 
You asked the Plan to waive the copayment for a specialist office visit. You say that that you want to make an 
appeal because you're being billed. The Plan denied your request. The Plan says 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 a $50 
copayment for each Medicare-covered specialist visit.  
 
You have been asked to pay a $50 copayment for a specialist office visit. A specialist office visit falls within 
the "Physician/Practitioner services, including doctor's office visits" 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 a specialist office visit (99213) on July 10, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the established patient office or other outpatient visit (99212) 
provided by an out of network (OON) provider. 
 
You asked the Plan to pay for the established patient office or other outpatient visit. 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 by the facility or the provider; therefore, payment has been correctly denied. 
 
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 established patient office or other outpatient 
visit (99212) provided 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 subsequent hospital care services coded 99232 and 99233 
provided. 
 
You asked the Plan to pay for the subsequent hospital care services. 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 supported by the 
documentation. 
 
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 99232 and 99233 are not supported in the medical record. Specifically, these codes 
were reported with another evaluation and management service (code 99291) on the same date by the same 
provider. Based on this information, we decided that Medicare rules for coverage of the subsequent hospital 
care services have not been met. Therefore, we decided that the Plan does not have to pay for the subsequent 
hospital care services coded 99232 and 99233 provided.