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

 
We decided that the Plan does not have to pay for the emergency department visit coded 99283 provided on 
February 17, 2020. 
 
You asked the Plan to pay for the emergency department visit. 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 99283 is emergency department visit for the evaluation 
and management of a patient, which requires these 3 key components: An expanded problem focused history; 
An expanded problem focused examination; and Medical decision making of moderate complexity. Counseling 
and/or coordination of care with other physicians, other qualified health care professionals, or agencies are 
provided consistent with the nature of the problem(s) and the patient's and/or family's needs. Usually, the 
presenting problem(s) are of moderate severity. 
 
We find that CPT code 99283 is not supported in the medical record. Specifically, this service was billed with 
diagnosis code T43505A (adverse effect of unspecified antipsychotics and neuroleptics, initial encounter). This 
service was not billed with the appropriate, first listed or principal diagnosis. A secondary only diagnosis 
cannot be used as the primary, first listed or principal diagnosis for any procedure or service. Based on this 
information, we decided that Medicare rules for coverage of the emergency department visit have not been met. 
Therefore, we decided that the Plan does not have to pay for the emergency department visit coded 99283 
provided on February 17, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for observation care discharge day management (CPT Code 
99217) provided on March 6, 2020. 
 
You asked the Plan to pay for the services. You say that the services were medically necessary. The Plan 
denied your request. The Plan says the services were 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 pay for the services. Our reviewer says that the 
requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found it appears that the initial history, presentation, and work-up suggested that his medication and 
alcohol use was related to his lightheadedness, and the enrollee would not require additional workup or 
monitoring as the Viagra would have worn off. As vitals appeared normal, there was no clear indication for 
observation status. Therefore, this request for such will be considered not medically necessary based on the 
documentation provided. 
 
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 observation care discharge day management (CPT Code 99217) provided on March 6, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the medical services provided on June 22, 2020 by an out-of-
network provider. 
 
You asked the Plan to pay for the medical services. You say that you believed the doctor was in-network. The 
Plan denied your request. The Plan says you do not have out-of-network benefits. 
 
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 June 22, 2020 by 
an out-of-network provider.
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 December 26, 2019. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says there is no network 
deficiency for these services. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The requested provider in this case is not a network provider with the Plan. The Plan has network providers 
available who can provide the 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 December 26, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for subsequent nursing facility care provided on March 19, 2020. 
 
You asked the Plan to pay for the subsequent nursing facility care. 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 
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 subsequent nursing facility care provided on March 19, 2020.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the physical therapy services rendered on May 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 procedure code 97530 is not supported. 
 
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 97530 is therapeutic activities, direct (one-on-one) 
patient contact (use of dynamic activities to improve functional performance), each 15 minutes. 
 
We find that CPT code 97530 is not supported in the medical record. Specifically, the record shows that five 
minutes were spent rendering services to the enrollee, which does not meet the threshold of 15 minutes of 
therapy. 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 physical therapy services rendered 
on May 2, 2020.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to waive the deductible for lab work provided by a participating 
provider on May 26, 2020. 
 
You asked the Plan to waive the deductible for lab work. You say that you were never told that you would owe 
anything for this. The Plan denied your request. The Plan says the correct deductible amount has been applied. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information. Your 
contract with the Plan says that there is a $250 deductible for outpatient diagnostic tests/laboratory.  
 
The item or service you asked the Plan to waive the deductible for falls within the benefit category outpatient 
diagnostic tests/laboratory. The Plan has followed Medicare rules by clearly disclosing in the contract that there 
is a $250 deductible for outpatient diagnostic tests/laboratory. This cost sharing is a contractual obligation that 
had not been met at the time lab work was received on May 26, 2020. The total amount you are being asked to 
pay is $41.88. Therefore, we decided that the Plan does not have to waive the deductible for lab work provided 
by a participating provider on May 26, 2020.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for home visit services (CPT 99509) provided to the enrollee 
from January 5, 2020 to January 11, 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 Medicare guidance says status code "I" = Not valid for Medicare purposes. 
 
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 99509 is "Home visit for assistance with activities of 
daily living and personal care." 
 
We find that CPT code 99509 is not supported in the medical record. Specifically, this code has a status 
indicator of I, which means that it is not valid for Medicare use. 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 visit services (CPT 99509) provided to the enrollee from January 5, 2020 to January 11, 
2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to reimburse you for the hearing aids purchased on January 31, 2020. 
 
You asked the Plan to reimburse you for the out-of-network brand of hearing aids. You say that you did not 
know you had to buy a preferred brand. The Plan denied your request. The Plan says your Evidence of 
Coverage shows that hearing aids are not covered out of network. 
 
Medicare does not pay for hearing aids or related services. However, the Plan offers a hearing aid benefit that 
exceeds Medicare coverage. For that reason, the plan's coverage rules apply in this case. The Plan pays for 
hearing aids only from a specific in-network brand. 
 
We looked at the file and the Plan's rules. Based on this information, we decided that the Plan's rules for 
coverage of hearing aids have not been met. Therefore, we decided that the Plan does not have to reimburse 
you for the hearing aids purchased out-of-network on January 31, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for arthrocentesis, aspiration and/or injection, major joint or 
bursa (eg, shoulder, hip, knee, subacromial bursa); without ultrasound guidance (CPT Code 20610) and 
hyaluronan or derivative, synvisc or synvisc-one, for intra-articular injection, 1 mg (CPT Code J7325) provided 
on November 27, 2019. 
 
You asked the Plan to pay for the services. You say that the claim should be paid. The Plan denied your 
request. The Plan says the services are not supported by the records. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
Current Procedural Terminology (CPT) code 20610 50 (1 unit) remains not supported. The submitted medical 
records do not indicate that arthrocentesis, aspiration and/or injection, major joint or bursa (eg, shoulder, hip, 
knee, subacromial bursa); without ultrasound guidance was performed. Therefore, the billed service cannot be 
verified. It is noted that multiple attempts were made to contact the provider for additional information.  We 
have insufficient documentation to corroborate the services so we can confirm Medicare coverage has been 
met.  
 
Healthcare Common Procedural Coding System (HCPCS) code J7325 (32 Unit) remains not supported. The 
submitted medical records do not indicate that hyaluronan or derivative, Synvisc or Synvisc-One, for intra-
articular injection, 1 mg was administered; therefore, the billed service and units cannot be verified. It is noted 
that multiple attempts were made to contact the provider for additional information. We have insufficient 
documentation to corroborate the services so we can confirm Medicare coverage has been met. 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 arthrocentesis, aspiration and/or injection, major joint or bursa 
(eg, shoulder, hip, knee, subacromial bursa); without ultrasound guidance (CPT Code 20610) and hyaluronan 
or derivative, synvisc or synvisc-one, for intra-articular injection, 1 mg (CPT Code J7325) provided on 
November 27, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an automatic blood pressure monitor provided on November 
14, 2019. 
 
You asked the Plan to pay for automatic blood pressure monitor. You say that you are appealing with records. 
The Plan denied your request. The Plan says the denial of payment for this item is correct, because this blood 
pressure monitor is not covered by Medicare under the circumstances. 
 
The Plan must follow Medicare rules. Medicare rules say that ambulatory blood pressure monitors are only 
covered for the limited conditions described above.  
 
We looked at the file and Medicare rules. The records submitted do not support that this blood pressure monitor 
was provided within Medicare's limited coverage conditions. Based on this information, we decided that 
Medicare rules for coverage of automatic blood pressure monitor have not been met. Therefore, we decided 
that the Plan does not have to pay for an automatic blood pressure monitor provided on November 14, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the injection rendered on March 9, 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 64492 is not supported. 
 
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 64492 is injection(s), diagnostic or therapeutic agent, 
paravertebral facet (zygapophyseal) joint (or nerves innervating that joint) with image guidance (fluoroscopy or 
CT), cervical or thoracic; third and any additional level(s) (List separately in addition to code for primary 
procedure). 
 
We find that CPT code 64492 is not supported in the medical record. Specifically, the operative report did not 
include documentation of a diagnostic or therapeutic agent injections of the cervical or thoracic paravertebral 
facet joint. 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 injection rendered on March 9, 
2020.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an ambulance trip provided by a 
participating provider on May 15, 2020. 
 
You asked the Plan to waive the copayment for an ambulance trip. You say that this copayment is way too 
high. You say that you walked into the ambulance yourself and you were only driven 10 minutes to the 
hospital. The Plan denied your request. The Plan says the correct copayment has been 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 $350 
copayment for ambulance services.  
 
You have been asked to pay a $350 copayment for an ambulance trip. The correct copayment has been applied 
to the services that were provided. An ambulance trip falls within the ambulance services 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 an ambulance trip provided by a participating provider on 
May 15, 2020.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for ambulance services provided on May 21, 
2020. 
 
You asked the Plan to waive the copayment for ambulance services. You say that you were taken against your 
will and disagree with the charges. The Plan denied your request. The Plan says the claims were processed 
correctly, and you are being charged the correct amount. 
 
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 $350 
copayment for ambulance services.  
 
You have been asked to pay a $350 copayment for ambulance services. Ambulance services fall within the 
ambulance services 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 ambulance services 
provided on May 21, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the durable medical supplies defined by codes (L1971, 
L3170, L0650, L1851, L2397, L3960, L3916) provided to the enrollee on March 23, 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 provided documentation did not include a valid itemized shipping billing invoice. 
 
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 a valid proof of delivery, or relevant medical records which support medical 
necessity for the supplies provided in this case. The itemized shipping/billing invoice that indicates the supplies 
has a shipped and delivered date that are before the billed date of service, therefore the services cannot be 
verfied. 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 the durable medical supplies defined by 
codes (L1971, L3170, L0650, L1851, L2397, L3960, L3916) provided to the enrollee on March 23, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the office visit (99214) provided on  
April 22, 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 $50 
copayment per visit to an in-network standard specialist.  
 
You have been asked to pay a $50 copayment for the telemedicine specialist office visit 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 copayment for the office visit (99214) provided on April 22, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the medical services provided on December 12, 2019 by an 
out of network (OON) provider. 
 
You asked the Plan to pay for the orthosis (L3809). You say that the claim should be paid. The Plan denied 
your request. The Plan says there are in network alternatives and there was no 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 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 December 12, 
2019 by an out of network (OON) provider.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home health services provided to the enrollee on August 
13, 2019. 
 
You asked the Plan to pay for home health services. You say that this was billed correctly. The Plan denied 
your request. The Plan says a final claim was not received. 
 
The Plan must follow Medicare rules. The rules say that after a RAP has been paid and a 60-day episode has 
been completed or the enrollee has been discharged, the home health agency must submit a claim to receive the 
rest of payment due for the episode. 
 
We looked at the claim submitted, the file and the Medicare rules. Based on this information, we decided that 
Medicare rules for completing the claim for home health services have not been met. Specifically, a final claim 
has not been su Therefore, we decided that the Plan does not have to pay for the home health services provided 
to the enrollee on August 13, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the wig rendered on August 30, 2019. 
 
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 a covered benefit. 
 
Medicare may pay for items which either meet the definition of DME or a prosthesis when these items are 
ordered by a physician. The Plan follows these same rules. 
 
In this case, although the wig may be appropriate, it does not meet the definition of the above benefit 
categories. It is not considered DME because it does not directly treat a medical condition. It does not meet the 
Medicare definition of a prosthetic because it does not replace an internal body organ or attached tissue. As 
such, it is noncovered by Medicare. Furthermore, the Plan does not offer a supplemental benefit which would 
provide coverage for a wig. Therefore, we decided that the Plan does not have to pay for the wig rendered on 
August 30, 2019.