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

 
We decided that the Plan does not have to pay for the medical services provided on January 29, 2020 by an out 
of network (OON) provider. 
 
You asked the Plan to pay for the medical services. You say that these services were medically necessary. The 
Plan denied your request. The Plan says unauthorized, non-plan care is not covered. 
 
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 January 29, 2020 
by an out of network (OON) provider.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the extremity study (93970) provided on February 26, 2020 
by an out of network (OON) provider. 
 
You asked the Plan to pay for an OON extremity study. You say that the enrollee was not aware this service 
required authorization. The Plan denied your request. The Plan says this service was 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 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 extremity study (93970) provided on February 
26, 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 the medical services provided on January 9, 2020 by an out 
of network (OON) provider. 
 
You asked the Plan to pay for the medical services. You say that these services were medically necessary. The 
Plan denied your request. The Plan says unauthorized, non-plan care is not covered 
 
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 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 January 9, 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 monitored anesthesia provided to the enrollee on April 17, 
2020. 
 
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 the records provided do not support the services billed. The Plan says that the medical 
records state the enrollee was administered total intravenous anesthesia with Propofol during an outpatient 
surgery. The Plan states the claim billed with modifier ?AA? indicating monitored anesthesiology care service.  
The Plan states per LCD L34980, local anesthesia or minimal conscious sedation may be appropriate if the 
documentation clearly establishes the need for such sedation in the specific enrollee. The Plan states the 
documentation sent does not clearly establish the need for such sedation.  In addition, per Optum 360 Encoder 
Pro CPT 01992 and 64483 and 64484 cannot be billed together, and no modifier is allowed. 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 records submitted do not support the services billed. 
Medicare rules for coverage of this service have not been met. Therefore, we decided that the Plan does not 
have to pay for monitored anesthesia provided to the enrollee on April 17, 2020.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to pay for emergency room services provided to the enrollee on 
February 28, 2020 and billed under code 99284. 
 
You asked the Plan to pay for this claim. You say that this claim should be paid. The Plan denied your request. 
The Plan says the same service has been previously submitted by the same physician group for the same 
enrollee for the same date of service. 
 
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, code 99284 cannot be paid as billed due to previous services billed to the enrollee for the same 
date of service by the same physician group. Medicare billing criteria are not met. Therefore, we decided that 
the Plan does not have to pay for emergency room services provided to the enrollee on February 28, 2020 and 
billed under code 99284.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the physical therapy evaluation rendered on September 23, 
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 procedure code 97163 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 97163 is physical therapy evaluation, high complexity, 
typical time with patient 45 minutes. 
 
We find that CPT code 97163 is not supported in the medical record. Specifically, there is no documentation of 
a high complexity physical therapy evaluation. 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 evaluation rendered on September 23, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the medical services provided on February 12, 2020 by an 
out of network (OON) provider. 
 
You asked the Plan to pay for the medical services. You say that you were not aware that this doctor was out of 
network. The Plan denied your request. The Plan says unauthorized, non-plan care is not covered. 
 
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 had network providers available 
who could have provided 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 February 12, 
2020 by an out of network (OON) provider.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the ambulance transportation service 
(A0427) and ambulance mileage (A0425) provided on April 25, 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 $265 
copayment for each covered, one-way ambulance trip by ground or water provided.  
 
You have been asked to pay a $265 copayment for the one-way ground ambulance trip 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 ambulance transportation service (A0427) and ambulance 
mileage (A0425) provided on April 25, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for enteral formula (B4152) provided on October 10, 2019. 
 
You asked the Plan to pay for enteral formula. You say that the necessary documentation has been submitted. 
The Plan denied your request. The Plan says there is no physician's order for these items. 
 
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 physician order for the supplies provided in this case. The submitted 
prescription request/letter of medical necessity is dated after these items were delivered.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 enteral formula (B4152) provided on October 10, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the intraoral periapical x-ray (D0220) and fluoride varnish 
application (D1206) provided on March 4, 2020. 
 
You asked the Plan to pay for the intraoral periapical x-ray (D0220) and fluoride varnish application (D1206). 
You say that you have coverage for two exams, two cleanings, one x-ray and one fluoride treatment. You say 
that you want to know why this isn't being paid. The Plan denied your request. The Plan says the services are 
not covered benefits. 
 
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 
intraoral periapical x-ray (D0220) and fluoride varnish application (D1206) provided on March 4, 2020.
Appeal type: Hospice
Decision: Unfavorable

 
We decided that the Plan does not have to pay for ambulance services provided on January 24, 2020. 
 
You asked the Plan to pay for ambulance services. You say that services were provided before the enrollee 
enrolled in hospice. You say that the claim should be reprocessed for payment. The Plan denied your request. 
The Plan says Original Medicare is responsible for payment. 
 
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 ambulance services provided on January 24, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for mechanical traction therapy (97012) provided by a 
chiropractor from March 26, 2020 to April 9, 2020. 
 
You asked the Plan to pay for mechanical traction therapy. You say that this service should be covered. The 
Plan denied your request. The Plan says this service is not covered under Medicare rules. 
 
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 service at issue is not manual manipulation of the spine. Therefore, we decided that 
the Plan does not have to pay for mechanical traction therapy (97012) provided by a chiropractor from March 
26, 2020 to April 9, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the nursing facility care (99308) provided on January 29, 
2020 by an out of network (OON) provider. 
 
You asked the Plan to pay for OON nursing facility care. You say that this was a medically necessary service 
provided in good faith. The Plan denied your request. The Plan says this service was 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 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 nursing facility care (99308) provided on 
January 29, 2020 by an out of network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the additional intraoral x-ray (D0230)for tooth #25provided on June 22, 2020.You asked the Plan to pay for the additional intraoral x-ray (D0230). You say that you thought the x-ray wasn't clear, so they had to retake it.The Plan denied your request. The Plan says this service is limited to one per calendar year.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, you also have a maximum benefit of one additional intraoral x-ray (D0230) per year.The records show that you received two additional intraoral x-rays on June 22, 2020, which exhausted your benefit. Therefore, we decided that the Plan does not have to pay for the additional intraoral x-ray (D0230) for tooth #25 provided on June 22, 2020.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve 24 additional home health physical therapy (PT) visits. 
 
You asked the Plan to pre-approve 24 additional home health physical therapy visits. You say that the 24 
additional home health physical therapy visits are medically necessary. The Plan denied your request. The Plan 
says the 24 additional home health physical therapy visits are not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that home health care services may be covered if it is 
medically necessary for the enrollee to receive skilled nursing or therapy. A doctor must certify the need for 
home health care services. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve 24 additional home health physical 
therapy visits. Our reviewer says that the 24 additional home health physical therapy visits are not medically 
necessary. Our physician reviewer found the remaining 24 visits of therapy is not generally accepted as specific 
and effective therapy for the enrollee's condition. The enrollee has had 24 home health PT visits approved and 
then an additional 20 to finalize a home exercise program.  He has made progress in therapy but the records do 
not indicate he requires the remaining 24 visits with the unique skills of a professional therapist to safely and 
effectively provide treatment. Services do not need to safely and effectively be performed only by a therapist, 
or under the supervision of a therapist. The enrollee was already approved therapy to finalize a home exercise 
program. The requested services are not part of a maintenance program and the specialized skill, knowledge 
and judgment of a qualified therapist is not required to establish, design and/or deliver a program to maintain 
the enrollee's current condition or to prevent or slow further deterioration. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of 24 additional home health physical therapy visits have not been met. Therefore, 
we decided that the Plan does not have to pre-approve 24 additional home health physical therapy (PT) visits.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. You say that IRF care is medically necessary. The Plan denied 
your request. The Plan says Medicare coverage criteria are not met. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described above. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found the complexity of the enrollee's nursing, medical and rehabilitation needs do not 
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The patient's 
medical status does not currently require intensive physician and nursing oversight only in an IRF. The 
documentation does not support that the enrollee's functional status requires an intensive rehabilitation therapy 
program provided in an IRF. We looked at this physician's review, the file, and Medicare rules. Based on this 
information, we decided that Medicare rules for coverage of IRF care have not been met. Therefore, we 
decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and 
services.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for surgical services provided to the enrollee on August 20, 2019 
and billed under code 27506-AS-RT. 
 
You asked the Plan to pay this claim. You say that these services should be covered by the Plan. The Plan 
denied your request. The Plan says Current Procedural Terminology (CPT) code 27506-AS RT (1 Units) 
remains not supported. The documentation submitted indicates that assistant surgical services were performed 
by a Surgical Technologist/Surgical First Assistant (CST/CSFA), Licensed surgical assistant (LSA). Although 
skilled, certified surgical technicians are not recognized for payment per the Center for Medicare/Medicaid 
Services (CMS) guidelines. Of note, per CMS/Medicare guidelines, the services of Surgical Technicians and 
RN First Assists (RNFA) are not eligible for separate reimbursement 
 
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, these services are being billed by an 
ineligible provider. Medicare rules for coverage of this claim have not been met. Therefore, we decided that the 
Plan does not have to pay for surgical services provided to the enrollee on August 20, 2019 and billed under 
code 27506-AS-RT.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the pain management services rendered on December 20, 
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 provider is not licensed. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for services only when they are 
furnished by a provider or supplier enrolled in the Medicare program. 
 
The file shows that the provider was not eligible for Medicare billing of services for the state of Illinois for the 
date of service at issue. Therefore, we decided that the Plan does not have to pay for the pain management 
services rendered on December 20, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the medical services to be provided by an out-of-
network provider. 
 
You asked the Plan to pre-approve the medical services. You say that you have problems with your vision and 
already have an appointment and would like approval to see the specialists. The Plan denied your request. The 
Plan says they have in-network providers (doctors and facilities) within a reasonable distance from your 
location that can provide this service or item at a lower cost. The Plan states if you want to pay a lower cost, 
then you must receive your care from an in-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 pre-approve care from out-of-network providers only in cases involving 
emergencies, out of area urgent care and care that cannot be provided by network providers. 
 
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. We found no exception that would require 
the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve 
the medical services to be provided by an out-of-network provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a back brace (L0457) provided to the enrollee on January 24, 
2020. 
 
You asked the Plan to pay for the back brace. You say that the claim should be paid. The Plan denied your 
request. The Plan says the medical record did not support the services billed. 
 
The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when the patient's medical 
record contains sufficient documentation of the patient's medical condition to substantiate the necessity for the 
type and quantity of items ordered and for the frequency of use.  
 
The record shows that documentation submitted did not indicate the provider discussed the need for the billed 
supply code, so the billed supply code cannot be verified. Additionally the physician documentation is almost a 
year prior to the order date of the back brace, which originates from an out of state pharmacy. The record does 
not support that the contractor verified or did an appropriate face to face encounter.  Therefore, we decided that 
the Plan does not have to pay for a back brace (L0457) provided to the enrollee on January 24, 2020.