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

 
We decided that the Plan does not have to pre-approve arthrodesis, posterior or posterolateral technique, single 
level; cervical below C2 segment (CPT Code 22600). 
 
You asked the Plan to pre-approve the services. You say that you have strength and nerve issues within your 
neck. The Plan denied your request. The Plan says you have not been shown to fail any treatment, not showing 
that you are suffering from foraminal stenosis, any major new problems/complications from a prior surgery or 
bone loss that would qualify you for a spinal fusion. 
 
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 services. Our physician reviewer 
found the records do not show any evidence of spinal instability, fracture, or lesion. There is no documented 
major neurologic deficit present. Criteria for spinal cervical fusion not met. 
 
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 pre-approve arthrodesis, posterior or posterolateral technique, single level; cervical below C2 segment 
(CPT Code 22600).
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a continuation of skilled nursing facility (SNF) care. 
 
You asked the Plan to pre-approve the continuation of SNF care. You say that the records provided support the 
need for continued SNF care. The Plan denied your request. The Plan says skilled services are no longer 
needed. The Plan says that the enrollee's current level of function does not require a SNF for safe delivery of 
care. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors 
listed above are met. Custodial care is 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 continuation of SNF care. Our 
reviewer says that daily skilled services are not necessary. Our physician reviewer found the enrollee received 
oral medications, had stable vital signs, and an intact incision. The enrollee received physical therapy and 
occupational therapy in the SNF. By the dates in question, the enrollee was at a set up to modified independent 
level with functional mobility, including gait to 300 feet with a rolling walker. The enrollee required varying 
assist with activities of daily living. There are no identifiable skilled therapy service needs. There are no 
identifiable skilled nursing service needs. The enrollee does not meet severity of illness or intensity of service 
criteria for an inpatient basis in a SNF setting. 
 
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 continuation of SNF care have not been met. Therefore, we decided that the 
Plan does not have to pre-approve a continuation of skilled nursing facility (SNF) care.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a home ventilator. 
 
You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied 
your request. The Plan says the services are not covered. 
 
The Plan must follow Medicare rules. The rules say that products currently classified as HCPCS code E0465 or 
E0466, when used to provide CPAP or bi-level PAP, are not payable. 
 
We looked at the file and Medicare rules. The file shows that the ventilator described by procedure code E0466 
is being requested to provide BiPAP. 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 pre-approve a home 
ventilator.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve balloon sinuplasty. 
 
You asked the Plan to pre-approve balloon sinuplasty. You say that the requested balloon sinuplasty is 
medically necessary. The Plan denied your request. The Plan says the requested balloon sinuplasty is 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 pre-approve balloon sinuplasty. Our reviewer says 
that the requested balloon sinuplasty is not medically necessary. Our physician reviewer found the enrollee is 
with a 10-year history of chronic sinus issues. He has had multiple sinus infections treated with antibiotics. A 
CT scan on 7/15/20 demonstrated deviation of the nasal septum, and normally pneumatized paranasal sinuses, 
with no obstructive changes.  
 
Balloon sinuplasty is used to dilate blocked sinus ostia. The procedure is not appropriate for patients who do 
not have positive findings of sinus disease on imaging studies. With no apparent obstruction of the sinuses on 
CT scan, the requested balloon sinuplasty is not medically reasonable and necessary for the enrollee in this 
case. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of balloon sinuplasty have not been met. Therefore, we decided that the Plan does 
not have to pre-approve balloon sinuplasty.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve supplies for a continuous glucose monitor (CGM) 
(K0553) provided September 23, 2019. 
 
You asked the Plan to pre-approve the supplies. You say that the supplies were medically necessary. The Plan 
denied your request. The Plan says coverage criteria was not met. 
 
The Plan must follow Medicare rules. Medicare rules say that every six (6) months following the initial 
prescription of the CGM, the treating practitioner must have an in-person visit with the beneficiary to assess 
adherence to their CGM regimen and diabetes treatment plan.  
 
We looked at the file and Medicare rules. The records show the last in person visit with the enrollee was greater 
than 6 months from the time the supplies were ordered. Based on this information, we decided that Medicare 
rules for coverage of the supplies have not been met. Therefore, we decided that the Plan does not have to pre-
approve supplies for a continuous glucose monitor (CGM) (K0553) provided September 23, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for long term electroencephalogram (EEG) monitoring with 
video (95951). 
 
You asked the Plan to pay for the long term EEG monitoring with video. You say that this was a clean claim at 
the time of initial submission which has been unnecessarily delayed by an invalid denial. You ask for a 
reconsideration of the claim and timely submission of payment. The Plan denied your request. The Plan says 
there is insufficient documentation to corroborate the services to confirm Medicare coverage has been met. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
In this case, CPT code 99591 is not supported in the medical record. Specifically, this code is missing the 
appropriate modifier needed for reporting a procedure with reduced services.  The submitted documentation 
indicates the video electroencephalographic recording time was less than 12 hours for the billed date of service. 
Based on this information, we decided that Medicare rules for coverage of the long term EEG monitoring with 
video have not been met. Therefore, we decided that the Plan does not have to pay for long term 
electroencephalogram (EEG) monitoring with video (95951).
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the subsequent nursing facility care, per day (99307) 
rendered by the out of network (OON) provider on January 17, 2020. 
 
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 was rendered by an out of network 
provider, without 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 provider in this case is not a network provider with the Plan. The Plan has network providers available 
who can provide the service at issue in this appeal. The Plan did not pre-approve the service at issue. We found 
no exception that would require the Plan to pay for this service. Therefore, we decided that the Plan does not 
have to pay for the subsequent nursing facility care, per day (99307) rendered by the out of network (OON) 
provider on January 17, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home infusion therapy services (S9328) provided from 
January 1, 2020 through February 15, 2020. 
 
You asked the Plan to pay for the home infusion therapy services (S9328). You say that you would like the 
Plan to reconsider their denial of payment. The Plan denied your request. The Plan says the services are not 
covered. 
 
The Plan must follow Medicare rules. The rules say that that home infusion services and supplies may be 
covered as a supplemental benefit. Home infusion therapy supplies are not covered by Original Medicare. The 
Plan does not include a mandatory supplemental benefit for home infusion therapy services or supplies.  
 
We looked at the file, Medicare rules, and the Plan's rules. Based on this information, we decided that 
Medicare rules for coverage of the home infusion therapy services have not been met. Therefore, we decided 
that the Plan does not have to pay for the home infusion therapy services (S9328) provided from January 1, 
2020 through February 15, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the speech generating device rendered on March 30, 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 there is no valid physician order. 
 
The Plan must follow Medicare rules. The rules say that a supplier must have an order from the treating 
physician before dispensing any DMEPOS item to a beneficiary. 
 
We looked at the file and Medicare rules. There is no valid physician order for the DME. 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 speech generating device rendered on March 30, 2020.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the outpatient rehabilitation services provided on June 2, 
2020 to June 29, 2020 by an out of network (OON) provider. 
 
You asked the Plan to pay for the outpatient rehabilitation services. You say that you were under the 
assumption that these services were being paid for. You were not aware that it needed an authorization since 
you went in last year. The Plan denied your request. The Plan says enrollees must receive their medical 
services from an in-network provider with the exception being urgent or emergent services. The plan says that 
non-emergent services with non-contracted providers require prior authorization before services being 
rendered. 
 
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 outpatient rehabilitation services provided on 
June 2, 2020 to June 29, 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) provided on May 6, 2020. 
 
You asked the Plan to waive the copayment 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 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). The enrollees contract with the Plan clearly says that enrollees 
must pay a $300 copayment per one-way trip for emergency and non-emergency ambulance services.  
 
The enrollee has been asked to pay a $300 copayment for the ambulance service provided. This means that the 
enrollee has been asked to pay the correct amount based on his contract with the Plan. This cost sharing is a 
contractual obligation the enrollee agreed to pay when he enrolled in the Plan. Therefore, we decided that the 
Plan does not have to waive the copayment for the ambulance transportation service (A0427) provided on  
May 6, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the domiciliary or rest home visit (99336) rendered by the 
out of network (OON) provider on January 1, 2020. 
 
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 was rendered by an out of network 
provider, without 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 provider in this case is not a network provider with the Plan. The Plan has network providers available 
who can provide the service at issue in this appeal. The Plan did not pre-approve the service at issue. We found 
no exception that would require the Plan to pay for this service. Therefore, we decided that the Plan does not 
have to pay for the domiciliary or rest home visit (99336) rendered by the out of network (OON) provider on 
January 1, 2020.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the medical services provided on March 19, 2020 by an out 
of network (OON) provider. 
 
You asked the Plan to pay for laboratory test. You say that you are appealing. The Plan denied your request. 
The Plan says the denial of payment for this service is correct, because this provider is out-of-network with the 
Plan and authorization was not obtained. 
 
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 March 19, 2020 
by an out of network (OON) provider.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the tissue transfer services rendered on January 24, 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 codes 14301 and 14302 are 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 14301 is adjacent tissue transfer or rearrangement, any 
area; defect 30.1 sq cm to 60.0 sq cm. The definition of code 14302 is adjacent tissue transfer or rearrangement, 
any area; each additional 30.0 sq cm, or part thereof (List separately in addition to code for primary procedure). 
 
We find that CPT codes 14301 and 14302 are not supported in the medical record. Specifically, the operative 
report does not include documentation of an adjacent tissue transfer of 30.1sq cm to 60sq cm to support code 
14301. Given that the primary procedure code 14301 is not supported, the add-on code 14302 is also not 
supported. 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 tissue transfer services rendered on 
January 24, 2020.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an outpatient surgery provided on March 
10, 2020. 
 
You asked the Plan to waive the copayment for an outpatient surgery. You say that you believed this would be 
a routine colonoscopy. The Plan denied your request. The Plan says the copayment you are being charged is 
correct. 
 
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 in-network surgery services in an outpatient hospital setting.  
 
You have been asked to pay a $350 copayment for an outpatient surgery in an outpatient hospital setting. An 
outpatient surgery falls within the outpatient surgery, including services provided at hospital outpatient 
facilities and ambulatory surgical centers, 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 outpatient surgery provided on March 10, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for Conforming bandage, non-elastic, knitted/woven, sterile 
(A6446) and specialty absorptive dressing, wound cover, sterile (A6252) provided April 3, 2020. 
 
You asked the Plan to pay for the surgical dressings. You say that emergency wound care was provided in the 
absence of another contracted/available wound care physician.  Please review and process payment for the 
medically necessary services rendered. The Plan denied your request. The Plan says these surgical supplies are 
not allowed because they were included in the related surgical procedure. 
 
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, we have confirmed that code the 
surgical dressings has a bundled relationship with code 11042 and 11043 and cannot be paid as billed. This 
code cannot be paid as a separate line item. Based on the claim submitted, Medicare billing criteria have not 
been met. Therefore, we decided that the Plan does not have to pay for Conforming bandage, non-elastic, 
knitted/woven, sterile (A6446) and specialty absorptive dressing, wound cover, sterile (A6252) provided April 
3, 2020.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the CYP panel rendered on October 25, 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 covered. 
 
The Plan must follow Medicare rules. The rules say that all CYP panels should be billed with 81479 and are 
non-covered. 
 
The testing at issue is a CYP panel. The file shows that the testing was not billed with the required 81479 code. 
Furthermore, this testing is not covered by Medicare. Therefore, we decided that the Plan does not have to pay 
for the CYP panel rendered on October 25, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for Direct skilled nursing services of a licensed practical nurse 
(LPN) in the home health or hospice setting, each 15 minutes (G0300) Direct skilled nursing services of a 
registered nurse (RN) in the home health or hospice setting, each 15 minutes (G0299)  provided January 2, 
2020 to January 27, 2020. 
 
You asked the Plan to pay for the skilled nursing home health services. You say that as you can see the enrollee 
was seen for medical necessity. Please review these ub4 claims and process them for payment. The Plan denied 
your request. The Plan says this claim was 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 claim was billed with type of bill 323, which is not payable. A corrected claim has not been 
received. Based on this information, we decided that Medicare rules for coverage of the skilled nursing home 
health services have not been met. Therefore, we decided that the Plan does not have to pay for Direct skilled 
nursing services of a licensed practical nurse (LPN) in the home health or hospice setting, each 15 minutes 
(G0300) Direct skilled nursing services of a registered nurse (RN) in the home health or hospice setting, each 
15 minutes (G0299)  provided January 2, 2020 to January 27, 2020.