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

We decided that the Plan does not have to pay for the subsequent observation care (99226) provided on 
September 1, 2019. 
 
You asked the Plan to pay for this service. You say that you are requesting a reconsideration of the Plan's 
denial for payment. The Plan denied your request. The Plan says the service is not payable as the claim was 
submitted untimely. 
 
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 this service was not filed until September 15, 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 the subsequent observation care (99226) provided on September 1, 2019.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approveplacement of spinal cord stimulator services.You asked the Plan to pre-approveplacement of spinal cord stimulator services. You say that you would like the plan to reconsider their denial.The Plan denied your request. The Plan says theThe Plan follows Medicare rules. Medicare rules say that placement of spinal cord stimulator is only covered to certain indications.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 placement of spinal cord stimulator services. Our reviewer says that the documentation does not support that the requested services are medically reasonable or necessary. Our physician reviewer found the enrollee has chronic low back pain. The enrollee has tried physical therapy and TENS. The enrollee is taking Gabapentin and Zanaflex for pain. The enrollee had a psychological evaluation and was cleared for the procedure. An MRI shows degenerative disc disease, disc herniation and spinal stenosis. A neurosurgery consult was requested but the results are not submitted for review. The enrollee does not have an evidence based indication for a spinal cord stimulator trial.
Therefore, the enrollee does not meet criteria for the requested services.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of placement of spinal cord stimulator services have not been met.Therefore, we decided that the Plan does not have to pre-approveplacement of spinal cord stimulator services
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the Iv tubing extension set coded S1015, the infection control 
supplies coded S8301, the tracheal suction catheter coded A4624, and the surgical masks coded A4928 
provided on September 4, 2020. 
 
You asked the Plan to pay for the Iv tubing extension set, the infection control supplies, the tracheal suction 
catheter, and the surgical masks. You say that you would like the plan to reconsider their denial. The Plan 
denied your request. The Plan says the items billed are not payable. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
 
We find that CPT codes S1015 and S8301 are not supported in the medical record. Specifically, codes S1015 
and S8301 have a status code of "I". A status code of I means that these codes are not valid for Medicare 
purposes. Medicare uses another code for reporting of, and payment of these services. 
Tracheal suction catheters (Code A4624) are only covered when the enrollee has a tracheostomy. Review of the 
file does not support that the enrollee has a tracheostomy. Surgical face masks (Code A4928) are non-covered 
as they are nonreusable disposable items. 
 
Based on this information, we decided that Medicare rules for coverage of the Iv tubing extension set, the 
infection control supplies, the tracheal suction catheter, and the surgical masks have not been met. Therefore, 
we decided that the Plan does not have to pay for the Iv tubing extension set coded S1015, the infection control 
supplies coded S8301, the tracheal suction catheter coded A4624, and the surgical masks coded A4928 
provided on September 4, 2020.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pre-approve sixty additional skilled nursing home health visits. 
 
You asked the Plan to pre-approve additional skilled nursing home health visits. You say that you need home 
health care. The Plan denied your request. The Plan says skilled nursing home health 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 additional skilled nursing home health 
visits. Our reviewer says that the requested home health visits are not medically necessary. Our physician 
reviewer found that the documentation does not support that you require skilled nursing services to provide 
treatment that is medically necessary. You do not require skilled nursing to effectively provide treatment, care, 
and/or services in order to improve your condition, perform a maintenance program to maintain your condition 
and/or prevent deterioration. You have been medically stable without any recent exacerbations of chronic 
medical problems or hospitalizations. The wound on your elbow is superficial and does not require complex 
dressing or local wound care. 

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of additional skilled nursing home health visits have not been met. Therefore, we 
decided that the Plan does not have to pre-approve sixty additional skilled nursing home health visits.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment forthe ambulance services provided June 6, 2020.You asked the Plan to waive the copayment forthe ambulance services. You say that you would like this copayment waived.The Plan denied your request. The Plan says the copayment has processed correctly in this case.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 $100 copayment for ambulance services.You have been asked to pay a $100 copayment for the ambulance services. The services provided 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 forthe ambulance services provided June 6, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plandoes not haveto pre-approvea semi-electric hospital bed for the enrollee.You asked the Planto pre-approvethe bed. You say that this is medically necessary.The Plandenied your request. The Plansaysthere is no requirement for frequent and immediate changes in body position.The Plan must follow Medicare rules. The rules say that a semi-electric hospital bed may be considered medically necessary when the patient:1. Has a medical condition which requires positioning of the body in ways not feasible with an ordinary bed; or2. Requires attachments which can only be attached to a hospital bed; AND3. Requires frequent changes in body position and/or has an immediate need for a change in body position.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 bed. Our reviewer says that the requested bed is not medically reasonable or necessary. Our physician reviewer found the documentation does not clearly reveal that the enrollee's condition has failed positioning of the bed in ways not feasible in an ordinary bed or why positioning of the bed in other ways is not feasible. The documentation does not support a need for an immediate or frequent changes in body position or special attachments that cannot be fixed on an ordinary bed. The request for a semi-electric hospital bed is not medically necessary for this enrollee.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 bed have not been met.Therefore, we decided that the Plandoes not haveto pre-approvea semi-electric hospital bed for the enrollee
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pay for the physical therapy services provided from September 2, 
2020, to September 25, 2020 by an out of network provider. 
 
You asked the Plan to pay for the physical therapy services. You say that the Plan should pay these claims. The 
Plan denied your request. The Plan says you did not obtain 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 had network providers 
available who could have provided 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 physical therapy services provided from September 2, 2020, 
to September 25, 2020 by an out of network provider.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for lab services provided January 2, 2019 to 
June 18, 2019. 
 
You asked the Plan to waive the coinsurance for the lab services. You say that the coinsurance should be 
waived. The Plan denied your request. The Plan says the correct cost-sharing was applied. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a 45% 
coinsurance for out-of-network laboratory services.  
 
You have been asked to pay a 45% coinsurance for the lab services. The lab services fall within the out-of-
network laboratory 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 coinsurance for lab 
services provided January 2, 2019 to June 18, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services provided on
You asked the Plan to pay for the laboratory services. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the services rendered are not a covered benefit.
The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few tests listed above, are not covered. The laboratory testing at issue in this appeal was requested solely for screening purposes. Medicare does not cover this test solely for screening purposes. Therefore, we decided that the Plan does not have to pay for the laboratory services provided on
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 October 8, 2020.You asked the Plan to waive the copayment for an ambulance trip. You say that he was not capable of standing or walking and could not be transported by private vehicle. 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). The enrollee's contract with the Plan clearly says that enrollees must pay a $150 copayment for ambulance services. The enrollee has been asked to pay a $150 copayment for an ambulance trip. Since an ambulance trip was provided, the correct copayment has been applied. An ambulance trip falls within the ambulance services benefit category. This means that the enrollee has been asked to pay the correct amount based on the contract with the Plan. This cost sharing is a contractual obligation the enrollee agreed to pay upon enrolling 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 October 8, 2020
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for laboratory services provided to the enrollee on June 5, 2020.
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. The Plan says the care was not approved in compliance with the health plan's authorization procedures.
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 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 laboratory services provided to the enrollee on June 5, 2020.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay forMohs micrographic technique provided on July 8, 2020.You asked the Plan to pay forthe Mohs micrographic technique (17311). You say that the Plan should pay this claim.The Plan denied your request. The Plan says the documentation submitted did not include a microscopic examination of specimens.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 17311 is Mohs micrographic technique, including removal of all gross tumor, surgical excision of tissue specimens, mapping, color coding of specimens, microscopic examination of specimens by the surgeon, and histopathologic preparation including routine stain(s) (eg, hematoxylinand eosin, toluidine blue), head, neck, hands, feet, genitalia, or any location with surgery directly involving muscle, cartilage, bone, tendon, major nerves, or vessels; first stage, up to 5 tissue blocks.We find that CPT code 17311 is not supported inthe medical record. Specifically, the record does not show a microscopic examination of specimens by the surgeon. Based on this information, we decided that Medicare rules for coverage of the Mohs micrographic technique have not been met.Therefore, we decided that the Plan does not have to pay forMohs micrographic technique provided on July 8, 2020
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the lab services provided on September 19, 2019. 
 
You asked the Plan to pay for the lab services. The Plan denied your request. The Plan says predictive 
screening testing is not a Medicare benefit. 
 
The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few 
tests listed above, are not covered. 
 
The testing at issue in this appeal was requested for screening purposes. The documentation does not indicate 
the testing was ordered to determine a specific treatment strategy or diagnosis. Medicare does not cover this 
testing for screening purposes. Therefore, we decided that the Plan does not have to pay for the lab services 
provided on September 19, 2019.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to waive the copayments for physical therapy services (97140, 97530, 
97110) provided from October 20, 2020, to October 29, 2020. 
 
You asked the Plan to waive the copayments for the physical therapy services. You say that the copayments 
should be waived. The Plan denied your request. The Plan says the correct cost-sharing was applied. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $35 
copayment for Outpatient Rehabilitation Services.  
 
You have been asked to pay a $140 in copayments for 4 physical therapy visits ($35 per visit). The physical 
therapy services fall within the Outpatient Rehabilitation 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 copayments for physical therapy services (97140, 97530, 97110) provided from October 20, 2020, 
to October 29, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a functional electrical stimulator.
You asked the Plan to pre-approve the stimulator. You say that this is medically necessary. The Plan denied your request. The Plan says the documentation received fails to indicate presence of muscle atrophy or a spinal cord injury.
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 pre-approve the stimulator. Our reviewer says that the requested stimulator is not considered medically reasonable and necessary in this case. Our physician reviewer found there is a history of an undefined upper motor neuron disorder causing symptoms. However, the applicable guidelines limit coverage to aid in ambulation to those patients with a history of spinal cord injury. You are not noted to have such an injury. 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 stimulator have not been met. Therefore, we decided that the Plan does not have to pre-approve a functional electrical stimulator.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for laboratory services (87150, 87481, 87491, 87500, 87511,
87529, 87591, 87640, 87641, 87651, 87653, 87661, 87798, 87801) provided on May 4, 2020.
You asked the Plan to pay for laboratory services. You say that this is supported in the records. The Plan
denied your request. The Plan says this was billed with an incorrect place of service code.
The Plan must follow Medicare rules. Medicare rules say that if an independent lab bills for services, the place
where the sample was taken is reported as the Place of Service (POS). An independent laboratory taking a
sample in its laboratory shows "81" as place of service.
We looked at the file and Medicare rules. The record shows that although these services were billed with POS
81, the specimen tested was not taken in the independent laboratory. Based on this information, we decided that
Medicare rules for coverage of laboratory services have not been met. Therefore, we decided that the Plan does
not have to pay for laboratory services (87150, 87481, 87491, 87500, 87511, 87529, 87591, 87640, 87641,
87651, 87653, 87661, 87798, 87801) provided on May 4, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment forthe office visit received on September 30, 2020.You asked the Plan to waive the copayment forthe office visit. You say that you feel the services received were part of the preventive visit.The Plan denied your request. The Plan says the claim has been processed correctly per your 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 $10 copayment for physician/practitioner services. You have been asked to pay a $10 copayment for the office visit. The office visit falls within the physician/practitioner services benefit category. Review of the file shows that other issues besides preventive issues were discussed during this visit. Therefore, non-preventive services were received during this visit and therefore, requirea copayment. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment forthe office visit received on September 30, 2020.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for wound care provided by a participating
provider on September 24, 2020, to October 8, 2020.
You asked the Plan to waive the copayment for wound care. You say that you do not agree with this
copayment. 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 $600
copayment for outpatient surgery/in-network.
You have been asked to pay less than a $600 copayment for wound care. The total amount you are being asked
to pay is $447.45 ($127.58 + $127.58 + $192.29 = $447.45) which is less than your copayment amount of
$1,800 ($600 x 3 visits = $1,800). Wound care falls within the outpatient surgery/in-network 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 wound care provided by a participating provider on
September 24, 2020, to October 8, 2020.
This appeal only addresses three dates of service. The other dates of services that you are appealing are being handled
separately.