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

 
We decided that the Plan does not have to pay for the laboratory services provided on May 8, 2020 by an out of 
network (OON) provider. 
 
You asked the Plan to pay for laboratory services. You say that the services rendered were medically necessary. 
The Plan denied your request. The Plan says prior authorization must be obtained for non-emergent services 
rendered 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 laboratory services provided on May 8, 2020 
by an out of network (OON) provider.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the air ambulance services provided on April 28, 2020. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says this is not medically 
necessary. 
 
The Plan follows Medicare rules. The rules say that Medicare pays for air ambulance services only if your 
medical condition is such that transportation by ground ambulance is not appropriate.  
 
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 
requested air ambulance services are not medically reasonable and necessary. Our physician reviewer found 
that the records do not outline care needs provided at the receiving hospital that were not available at the 
originating facility. There were no records from the originating facility available for review. There are no 
physician statements outlining the medical necessity for the transfer. Without this documentation, medical 
necessity for transfer to a different medical facility cannot be determined. Coverage for air medical transfer 
cannot be determined medically necessary. 
 
 
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 the air ambulance services provided on April 28, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay forthe services (CPT 99152, CPT 99153) provided on August 6, 2019.You asked the Plan to pay forthe services. The Plan denied your request. The Plan says the billed services cannot be verified.The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code.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 use of the requested CPT codes are not supported by the records provided. Our physician reviewer found that the medical records provided document services performed on July 25, 2019.  There is not documentation supporting services performed on August 6, 2019. 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 forthe services (CPT 99152, CPT 99153) provided on August 6, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for the continuous positive airway pressure 
(c-pap) device rental (E0601RR) and the heated humidifier rental (E0562RR) provided on June 16, 2020. 
 
You asked the Plan to waive the coinsurance. You say that you are requesting a reconsideration of the Plan's 
denial for payment. The Plan denied your request. The Plan says the coinsurance has been applied correctly to 
the durable medical equipment 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 20% 
coinsurance of the Plan-allowed amount for in-network Medicare-covered durable medical equipment.   
 
You have been asked to pay $21.15 ($105.76 Plan allowed amount x 20% coinsurance) for the in-network 
Medicare-covered durable medical equipment provided. 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 the continuous positive airway pressure (c-pap) device rental (E0601RR) and the heated humidifier rental 
(E0562RR) provided on June 16, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to waive the copaymentfor the programming device evaluations(93280) provided from January 29, 2020, through June 3, 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 services provided.The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $10 copayment for diagnostic tests andprocedures. You have been asked to pay $30 ($10 copayment x 3) for the diagnostic tests provided. 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 copaymentfor the programming device evaluations(93280) provided fromJanuary 29, 2020, through June 3, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for the continuous positive airway pressure 
(c-pap) device rental (E0601RR) and the heated humidifier rental (E0562RR) provided on May 16, 2020. 
 
You asked the Plan to waive the coinsurance. You say that you are requesting a reconsideration of the Plan's 
denial for payment. The Plan denied your request. The Plan says the coinsurance has been applied correctly to 
the durable medical equipment 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 20% 
coinsurance of the Plan-allowed amount for Medicare-covered durable medical equipment.  
 
You have been asked to pay $21.15 ($105.76 Plan allowed amount x 20% coinsurance) for the durable medical 
equipment provided. 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 the continuous positive airway 
pressure (c-pap) device rental (E0601RR) and the heated humidifier rental (E0562RR) provided on May 16, 
2020.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the services (CPT 20611) provided on March 12, 2020. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the billed service 
cannot be verified. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
In this case, the CPT Code Manual definition of code 20611 is "Arthrocentesis, aspiration and/or injection, 
major joint or bursa (eg, shoulder, hip, knee, subacromial bursa); with ultrasound guidance, with permanent 
recording and reporting". 
 
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 use 
of CPT code 20611 is not supported by the records provided. Our coding reviewer found that the medical 
records provided do not include permanent recording and reporting of an arthrocentesis, aspiration and/or 
injection, major joint or bursa (eg, shoulder, hip, knee, subacromial bursa) being performed on the left knee. 
Therefore, this service cannot be verified. 
 
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 the services (CPT 20611) provided on March 12, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services (80053, 80061, 83036, 85025) 
provided on June 18, 2020, by an out of network (OON) provider. 
 
You asked the Plan to pay for the laboratory services. You say that you were not aware you were out-of-
network. 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 laboratory services (80053, 80061, 83036, 
85025) provided on June 18, 2020, by an out of network (OON) provider.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for CPT code 29823-Arthroscopy, shoulder, surgical; 
debridement, extensive provided on January 21, 2020. 
 
You asked the Plan to pay for CPT code 29823. You say that the medical records support the billing of CPT 
code 29823. The Plan denied your request. The Plan says the medical records do not support the billing of CPT 
code 29823. 
 
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 29823 is Arthroscopy, shoulder, surgical; debridement, 
extensive. 
 
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 CPT code 29823. Our reviewer says that the 
medical records do not support the billing of CPT code 29823. Our physician reviewer found based on the 
documentation provided, the operative note does not describe extensive debridement. The code is not 
supported. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of CPT code 29823 have not been met. Therefore, we decided that the Plan does 
not have to pay for CPT code 29823-Arthroscopy, shoulder, surgical; debridement, extensive provided on 
January 21, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the subsequent nursing facility care (99309) provided on 
December 20, 2019 by an out of network (OON) provider. 
 
You asked the Plan to pay for nursing facility care. You say that medically necessary services were provided in 
good faith. The Plan denied your request. The Plan says prior authorization must be obtained for non-emergent 
services rendered 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 subsequent nursing facility care (99309) 
provided on December 20, 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 for the computerized ophthalmic diagnostic 
imaging (92134) provided on May 14, 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 $30 
copayment for diagnostic tests and procedures rendered at an in-network specialist's office.  
 
You have been asked to pay a $30 copayment for the diagnostic test provided at an in-network specialist's 
office. 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 computerized ophthalmic diagnostic 
imaging (92134) provided on May 14, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a shoulder-hand-wrist orthosis (L3960) provided to the 
enrollee on April 8, 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 physician order was lacking a date. We saw a date on the form so we examined the 
case for medical necessity. 
 
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 orthosis. Our reviewer says that the 
requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found the documentation in the case file does not support that the requested shoulder/arm orthosis was 
medically reasonable and necessary for the enrollee in this case. A physical examination of the shoulder would 
reasonably be required to adequately assess whether the shoulder/arm orthosis was medically necessary for an 
enrollee. The documentation does not support that the orthosis was medically reasonable and necessary for the 
enrollee in this case, as there is insufficient documentation of a credible physical examination of the shoulder. 
 
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 orthosis have not been met. Therefore, we decided that the Plan does not 
have to pay for a shoulder-hand-wrist orthosis (L3960) provided to the enrollee on April 8, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit (99205) provided March 20, 2019. 
 
You asked the Plan to pay for the office visit. You say that the service was medically necessary. The Plan 
denied your request. The Plan says the claim was not filed timely. 
 
The Plan follows Medicare rules. The rules say that claims for services furnished on or after January 1, 2010, 
must be filed no later than one calendar year after the date of service. 
 
The record shows that a claim for the office visit was not filed until May 12, 2020. This means that more than 
one calendar year from the date of service had passed before a claim was filed. Therefore, we decided that the 
Plan does not have to pay for an office visit (99205) provided March 20, 2019.
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 claim should be paid. The 
Plan denied your request. The Plan says the documentation did not reflect the presence of lymphedema or 
chronic venous insufficiency with venous stasis ulcers. 
 
The Plan follows Medicare rules. The rules state that Medicare covers pneumatic devices when medically 
necessary for the treatment of lymphedema and/ or for the treatment of chronic venous insufficiency with 
venous stasis ulcers. 
 
The file does not show that the enrollee has lymphedema and/ or chronic venous insufficiency with venous 
stasis ulcers. Therefore, we decided that the Plan does not have to pay for intermittent limb compression 
device.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for physician services provided to the enrollee on October 1, 
2019 and billed under code 95868. 
 
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 Medicare billing criteria were not met. 
 
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 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 this service. Our reviewer says that Medicare billing criteria are not met. Our physician 
reviewer found the medical records provided do not include documentation of a Needle electromyography; 
cranial nerve supplied muscles, bilateral being performed on October 1, 2019, therefore this service cannot be 
verified. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of this service have not been met. Therefore, we decided that the Plan does not 
have to pay for physician services provided to the enrollee on October 1, 2019 and billed under code 95868.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pay for physician services provided to the enrollee on March 18, 
2020 and billed under code 97140. 
 
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 Medicare billing criteria are not met. 
 
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 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 this service. Our reviewer says that Medicare billing criteria are not met. Our physician 
reviewer found the medical records provided do not include documentation of a therapeutic procedure, 1 or 
more areas, each 15 minutes; therapeutic exercises to develop strength and endurance, range of motion and 
flexibility or Manual therapy techniques (eg. mobilization/manipulation, manual lymphatic drainage, manual 
traction), 1 or more regions, each 15 minutes being performed. Therefore, the services cannot be verified.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of this service have not been met. Therefore, we decided that the Plan does not 
have to pay for physician services provided to the enrollee on March 18, 2020 and billed under code 97140.
Appeal type: Practitioner Services
Decision: Favorable

We decided that the Plan has to pay forsurgical services (CPT 27236) provided to the enrollee on February 2, 2020.You asked the Plan to pay forthe services. You say that this should be paid for.The Plan denied your request. The Plan says that the documentation does not support the date of 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 27236 is "Open treatment of femoral fracture, proximal end, neck, internal fixation or prosthetic replacement."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 supported by the medical records. Our coding reviewer found the date of service is documented five times on the operative report. Therefore, the date of service can be verified as February 2, 2020.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 been met.Therefore, we decided that the Plan has to pay forsurgical services (CPT27236) provided to the enrollee on February 2, 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 toreview. 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.