Persius/hicric huggingface dataset:
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an enteral feeding supply kit (HCPCS B4034) provided to 
the enrollee on December 30, 2019. 
 
You asked the Plan to pay for the supply kit. You say that this should be paid for. The Plan denied your 
request. The Plan says Healthcare Common Procedure Coding System (HCPCS) code B4034 (30 units) 
remains 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 HCPCS code B4034 is "Enteral feeding supply kit; syringe 
fed, per day, includes but not limited to feeding/flushing syringe, administration set tubing, dressings, tape." 
 
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 supply kit. Our reviewer says that the 
services at issue in this case were not supported by the medical records. Our coding reviewer found the 
ocumentation did not include signed proof of delivery to confirm patient received item.  Documentation did not 
include physician order for supplies needed. Documentation included a progress note dated December 27, 2019 
"Received a call from patients wife for refill.  The patient is still taking about 6 cans per day of Glucerna 
1.5Cal. Went over supplies and she stated that she did not need any supplies at this time just the formula. Plan 
is to courier out on Monday 12/30/2019 between 5-7 pm." Coverage has not been confirmed. 
 
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 supply kit have not been met. Therefore, we decided that the Plan does not 
have to pay for an enteral feeding supply kit (HCPCS B4034) provided to the enrollee on December 30, 2019.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the surgical services rendered on February 25, 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 13121 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 13121 is repair, complex, scalp, arms, and/or legs; 2.6 cm 
to 7.5 cm. 
 
We find that CPT code 13121 is not supported in the medical record. Specifically, there is no documentation of 
a complex repair of the scalp, arms, and/or legs of 2.6 cm to 7.5 cm was performed. 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 surgical services rendered on February 25, 2020.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for ambulance services you had on May 29, 
2020. 
 
You asked the Plan to waive the copayment for the ambulance services. You say that your doctor told you that 
the ambulance company would not charge you for the trip home from the hospital. The Plan denied your 
request. The Plan says you were charged this copayment amount correctly. 
 
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 $250 
copayment for ambulance services per trip.  
 
You have been asked to pay a $182 copayment for the ambulance services because the allowed amount for 
these ambulance services is less than your $250 copayment responsibility.  This copayment applies regardless 
of the reason or need for the transport. 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 
you had on May 29, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the parenteral nutritional solution provided from January 19, 
2019 to January 25, 2019 billed with 42 units of B4185. 
 
You asked the Plan to pay for the parenteral nutrition solution. You say that the records support the medical 
necessity of this treatment. The Plan denied your request. The Plan says there was no valid proof of delivery 
with an itemized delivery ticket showing what items were provided. 
 
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 for the supplies provided in this case. There is no delivery 
ticket/packing slip showing what was included in the shipment box nor was there a delivery confirmation 
corresponding to the dates of service at issue. A delivery confirmation for November 2018 was submitted but 
this is not relevant to this claim. 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 parenteral 
nutritional solution provided from January 19, 2019 to January 25, 2019 billed with 42 units of B4185.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the medical services provided on February 11, 2020 by an 
out of network (OON) provider. 
 
You asked the Plan to pay for laboratory testing. You say that the enrollee's treating physician sent the 
specimen to your lab, and you do not have information on the enrollee's insurance requirements, limitations, or 
conditions. The Plan denied your request. The Plan says the denial of payment for these services is correct, 
because this provider is out-of-network with the Plan and the ordering provider is also out-of-network with the 
Plan. 
 
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 February 11, 
2020 by an out of network (OON) provider.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a bone graft (20902) provided on January 6, 2020. 
 
You asked the Plan to pay for the bone graft. You say that you would like reconsideration based on the records 
submitted. The Plan denied your request. The Plan says the documentation submitted does not support the 
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 20902 is bone graft, any donor area; major or large.  
 
We asked our coder 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 bone graft. Our reviewer says that CPT code 20902 does 
not meet criteria for billing or reimbursement consideration. Our reviewer found the documentation did not 
include a major or large bone graft any donor.  The operative report documents bone marrow aspiration.  
Therefore this code 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 bone graft have not been met. Therefore, we decided that the Plan does not 
have to pay for a bone graft (20902) provided on January 6, 2020.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pay for physical and occupational therapy provided by an out-of-
network provider from February 6, 2020 through February 28, 2020. 
 
You asked the Plan to pay for physical and occupational therapy. You say that without therapy the enrollee 
would have experienced a decline in functional mobility and activities of daily living. You say that non-skilled 
personnel could not make the skilled decisions to achieve the desired outcome. The Plan denied your request. 
The Plan says network providers must be used to receive medical care and 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 physical and occupational therapy provided by an 
out-of-network provider from February 6, 2020 through February 28, 2020.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the interpretation of the limited duplex scan of extremity 
veins provided on April 24, 2020 billed with code 93971-26. 
 
You asked the Plan to pay for the duplex interpretation. You say that this should be covered. The Plan denied 
your request. The Plan says while the records do support that this is a separately payable service, this was not 
billed correctly. A new claim with an appropriate modifier must be submitted for payment to be considered. 
 
The Plan must follow Medicare rules. Medicare rules say that for PTP edits with a modifier indicator of 1, the 
Column 2 code is only payable when billed with a clinically appropriate NCCI modifier.  
 
In this case, code 93971 is a Column 2 code in relation to code 93970, which was billed for the same date of 
service by the same physician. No modifier was appended to the Column 2 code to allow for the edit to be 
bypassed. Therefore, we decided that the Plan does not have to pay for the interpretation of the limited duplex 
scan of extremity veins provided on April 24, 2020 billed with code 93971-26.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the four periodontal scalings and root planings, drugs or 
medicaments dispensed in the office for home use, periodontal maintenance, four gingival irrigations, topical 
application of fluoride varnish, three anterior resin-based composites of three surfaces, pin retention, and 
posterior resin-based composite of three surfaces provided from April 24, 2019 to September 12, 2019. 
 
You asked the Plan to pay for the scalings and planings, drugs or medicaments, periodontal maintenance, 
gingival irrigations, topical application of fluoride varnish, resin-based composites, and pin retention. You say 
that you were initially told the Plan would not cover these services, so you used another option. You also say 
that you need help getting the remaining dental services you need completed. The Plan denied your request. 
The Plan says these services are not covered under the plan. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plan's coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the four 
periodontal scalings and root planings, drugs or medicaments dispensed in the office for home use, periodontal 
maintenance, four gingival irrigations, topical application of fluoride varnish, three anterior resin-based 
composites of three surfaces, pin retention, and posterior resin-based composite of three surfaces provided from 
April 24, 2019 to September 12, 2019.  
 
Your complaint about the issues incurred during your dental treatments is not a valid appeal for medical 
coverage. This part of your complaint is a grievance that must be answered by the Plan. Medicare does not 
permit us to make a decision about these types of complaints.
Appeal type: Imaging
Decision: Favorable

 
We decided that the Plan has to pay for the portable x-ray services rendered on January 10, 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 that the claim is not payable as billed. 
 
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and 
diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or 
payment. 
 
The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their 
decision to deny your request. The Plan states that procedure codes R0070 and Q0092 have a PC/TC indicator 
of 3 and cannot be billed with the -26 modifier. While this is correct, the documentation does not show that the 
codes were billed with the -26 modifier. There is no documentation to support that the claim is not payable as 
billed. Therefore, we decided that the Plan has to pay for the portable x-ray services rendered on January 10, 
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 to review. 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.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the services (CPT 99190) provided on March 4, 2020. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says payment for these 
services is included in the Part A DRG payment to the facility. 
 
The Plan must follow Medicare rules. Medicare rules say that CMS does not pay any provider or supplier other 
than the facility or hospital for services furnished to a beneficiary. The facility or hospital must furnish all 
necessary covered services to the beneficiary either directly or under arrangements made with outside 
providers. Payment for all fees related to this service would have been included under the facility claim. 
Therefore, we decided that the Plan does not have to pay for the services (CPT 99190) provided on March 4, 
2020.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copay for the ultrasound provided on March 2, 2020. 
 
You asked the Plan to waive the copay for the services provided. You say that the copay should be $20. The 
Plan denied your request. The Plan says you are responsible for the cost share as outlined in the plan benefits. 
 
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 $145 
copay for each Medicare-covered radiological diagnostic service.  
 
You have been asked to pay $109.24 for the service provided. Because the amount is less than the $145 copay, 
you were charged the lesser amount. The services fall within the outpatient diagnostic tests 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 copay for the ultrasound provided on March 2, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the urological supplies provided on April 24, 2020. 
 
You asked the Plan to pay for the urological supplies. You say that these supplies have been paid by Medicare 
in the past. The Plan denied your request. The Plan says this claim cannot be paid separately based on Medicare 
guidelines for inpatient services. 
 
The Plan must follow Medicare rules. The rules say that Medicare does not pay any provider or supplier other 
than the facility or hospital for services furnished to an enrollee.  
 
Records show that the urological supplies were used in a SNF under a Part A stay. Medicare says these 
supplies are included in the skilled nursing facility PPS payment whether rendered directly or through a vendor. 
Therefore, we decided that the Plan does not have to pay for the urological supplies provided on April 24, 
2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the services provided on December 25, 2019. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the enrollee was 
enrolled in hospice. 
 
Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice 
services. Original Medicare is responsible for payment for services until the first day of the month after the 
hospice election has been revoked or terminated. 
 
The enrollee ended Medicare Hospice benefits on December 23, 2019. The services in question were provided 
before the end of that month. Therefore, we decided that the Plan does not have to pay for the services provided 
on December 25, 2019.
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 November 4, 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 November 4, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the critical care services provided on February 26, 2020. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the billed code cannot 
be verified. 
 
The Plan must follow Medicare rules. Medicare 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 on February 26, 
2020.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve home health physical therapy services (G0151). 
 
You asked the Plan to pre-approve the home health physical therapy services. You say that you are requesting 
reconsideration for continued home health physical therapy. The Plan denied your request. The Plan says the 
request for additional home health visits for physical therapy do not meet the criteria. 
 
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 the home health physical therapy 
services. Our reviewer says that medical necessity cannot be established for continued home health physical 
therapy. Our physician reviewer found the requested therapy is not generally accepted as specific and effective 
therapy for the enrollees condition. The enrollee has had prior therapy and the records do not indicate she 
requires the ongoing 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 trained in a home exercise program and met her goals per a therapy and discharged 
from therapy 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 enrollees 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 the home health physical therapy services have not been met. Therefore, we 
decided that the Plan does not have to pre-approve home health physical therapy services (G0151).
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ambulance services. 
 
You asked the Plan to pay for the ambulance services. You say that on the date of service you were having a 
bad reaction to a steroid and antibiotic medication. You say that when the ambulance arrived, the responders 
recommended that you do not go to the hospital due to the Covid-19 pandemic. You stated that you decided to 
remain at home while your home health aide and daughter took care of you through the pandemic. You asked 
the Plan to reconsider their decision and cover the cost of the ambulance response services. The Plan denied 
your request. The Plan says these services are not a covered benefit. 
 
The Plan must follow Medicare rules. The rules say that Medicare does not pay for ambulance services when 
there is no transport.  
 
The ambulance company did not provide transport services on March 19, 2020. The ambulance benefit is a 
transportation benefit. When there is no transport, neither Medicare nor the Plan pays for the services provided. 
Therefore, we decided that the Plan does not have to pay for the ambulance services.