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

 
We decided that the Plan does not have to pay for the home health evaluation (G0179) provided on February 
16, 2020 by an out of network (OON) provider. 
 
You asked the Plan to pay for an OON home health evaluation. You say that this was medically necessary. The 
Plan denied your request. The Plan says this 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 home health evaluation (G0179) provided on 
February 16, 2020 by an out of network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for drug injections, laboratory services, and 
office visits provided from October 24, 2019 to November 13, 2019. 
 
You asked the Plan to waive the coinsurance for drugs, lab services, and office visits. You say that you were 
never billed for these amounts, but they have now been sent to a collection agency. The Plan denied your 
request. The Plan says the cost-sharing amounts you are being charged are 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 20% 
coinsurance for drugs, 10% coinsurance for lab services, $10 copayment for primary care visit, and $40 
copayment for specialist visit. The allowed amount of the Part B drugs total $33.38, resulting in a coinsurance 
amount of $6.68. The allowed amounts of the lab services total 46.70, resulting in a coinsurance amount of 
$4.67. There was 1 primary care visit, resulting in a $10 copayment. There were 2 specialist copayments, 
resulting in a copayment amount of $80. Your total cost-sharing obligation is therefore $101.35. 
 
You have been asked to pay 20% coinsurance for drugs, 10% coinsurance for lab services, $10 copayment for 
primary care visit, and $40 copayment for specialist visit. Drugs, lab services, and office visits fall within the 
"Medicare Part B Prescription Drugs", "Outpatient Diagnostic Tests and Therapeutic Services and Supplies", 
and "Physician/Practitioner Services, Including Doctor's Office Visits" benefit categories. 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 drug injections, laboratory services, and office 
visits provided from October 24, 2019 to November 13, 2019.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a Skilled Nursing Facility (SNF) stay 
provided from March 5, 2020 to March 31, 2020. 
 
You asked the Plan to waive the copayment for a SNF stay. You say that the enrollee was not properly cared 
for. 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 $0 
copayment for per day for days 1-20 and a $125 copayment per day for days 21-100 for in-network SNF care.  
 
You have been asked to pay an $875 copayment for days 21-27 of the SNF stay ($125 x 7 days). A SNF stay 
falls within the Skilled Nursing Facility (SNF) care 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 a Skilled Nursing Facility (SNF) stay provided from March 5, 2020 to March 31, 2020.  
 
Maximus Federal Services read your letter and knows that you may have a quality of care concern. Maximus 
Federal Services cannot address quality of care issues. We are forwarding your quality of care concern to the 
appropriate Quality Improvement Organization for further review.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ambulance services you provided on April 3, 2020. 
 
You asked the Plan to pay for the ambulance services. You say that you were following the COVID executive 
order for treatment in place. 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 April 3, 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 you provided on April 3, 
2020.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pay for hot or cold pack therapy (97010) provided on February 25, 
2020. 
 
You asked the Plan to pay for the hot or cold pack therapy. You say that you would like reconsideration 
because CPT code 97010 is a separate service. The Plan denied your request. The Plan says CPT code 97010 is 
considered a bundled 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, we have confirmed that code the hot 
or cold pack therapy has a bundled relationship with code 97110 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 hot or cold pack therapy (97010) provided on 
February 25, 2020.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the medical services provided on July 16, 2019 by an out of 
network (OON) provider. 
 
You asked the Plan to pay for laboratory testing. You say that these tests were medically necessary and ordered 
by the enrollee's treating physician. 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 physician 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 July 16, 2019 by 
an out of network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for physician services provided on May 23, 2020 by an out of 
network (OON) provider. 
 
You asked the Plan to pay for physician services. You say that you are not required to obtained prior 
authorization. The Plan denied your request. The Plan says prior authorization is required and was not obtained. 
The Plan says that the member's primary care physician did not refer 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 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 physician services provided on May 23, 2020 by 
an out of network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab work provided on March 17, 2020 by an out of network 
(OON) provider. 
 
You asked the Plan to pay for lab work. You say that you would like this claim reprocessed and approved for 
payment. The Plan denied your request. The Plan says prior authorization was not obtained. The Plan says that 
the referring provider is also out-of-network. 
 
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 lab work provided on March 17, 2020 by an out of 
network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the medical services provided on January 14, 2020 by an out 
of network (OON) provider. 
 
You asked the Plan to pay for hereditary cancer screening tests. You say that 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, the 
referring provider is out-of-network with the Plan, and tests with no relation to a diagnosis for the health of the 
enrollee are not a covered benefit. 
 
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 14, 2020 
by an out of network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a knee orthosis (L1851) and a suspension sleeve addition to 
the lower extremity orthosis (L2397) billed for date of service March 2, 2020. 
 
You asked the Plan to pay for the knee orthosis and suspension sleeve addition. You say that the records 
provided support the medical necessity of the items in dispute. The Plan denied your request. The Plan says the 
guidelines for coverage have not been met. 
 
The Plan follows Medicare rules. Medicare rules say that HCPCS code L1851 is covered when specific criteria 
have been met and when medically necessary. Medicare rules also say that addition codes will be denied as not 
reasonable and necessary if the base orthosis is not reasonable and necessary. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pay for the knee orthosis and suspension sleeve 
addition.  
 
 
Our reviewer says that the criteria for coverage have not been met. Our physician reviewer found the 
documentation in the case file does not support that the requested knee orthoses with sleeves were medically 
reasonable and necessary for the enrollee in this case, according to the coverage criteria established by the 
LCD. There is no documentation of recent injury to, or recent surgical procedure on, either of the enrollee's 
knees, and there is insufficient credible objective documentation of joint laxity. 
 
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 knee orthosis and suspension sleeve addition have not been met. Therefore, 
we decided that the Plan does not have to pay for a knee orthosis (L1851) and a suspension sleeve addition to 
the lower extremity orthosis (L2397) billed for date of service March 2, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the outpatient services provided February 3, 2020. 
 
You asked the Plan to pay for the outpatient services. You say that you are appealing regarding payments for 
services delivered to the enrollee. The Plan denied your request. The Plan says there is not enough information 
to determine how the enrollee came to the servicing provider or whether the services are medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that this plan will generally cover your medical care 
as long as the care you receive is considered medically necessary and you receive your care from a provider 
who is eligible to provide services under Original Medicare.  
 
Non-contracted providers are required to furnish necessary information to the health plan when requested. The 
plan has made multiple attempts to obtain the medical records from the servicing provider and none were 
received. Based on this information, we decided that Medicare rules for coverage of the outpatient services 
have not been met. Therefore, we decided that the Plan does not have to pay for the outpatient services 
provided February 3, 2020.
Appeal type: Lab
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 June 21, 2019. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the services are 
available in-network. 
 
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 June 21, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lumbar-sacral orthosis (L0650) provided on March 27, 2020. 
 
You asked the Plan to pay for the lumbar-sacral orthosis. You say that you would like reconsideration because 
the back brace was medically necessary. The Plan denied your request. The Plan says the documentation 
submitted did not include a physician order or valid proof of delivery for the billed supply. 
 
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. Specifically, the 
documentation submitted does not include an itemized billing/shipping invoice to verify the supplies and the 
delivery ticket is for a different date than what was billed. 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 lumbar-sacral orthosis (L0650) provided on March 27, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the new doctor visit 99204) provided on August 19, 2019 by 
an out of network (OON) provider. 
 
You asked the Plan to pay for the doctor visit. You say that the doctor came to where you live in a mobile unit. 
You asked him if he was a contracted provider and he said yes. The Plan denied your request. The Plan says 
enrollee's 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 new doctor visit 99204) provided on August 
19, 2019 by an out of network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Favorable

 
We decided that the Plan has to pay for lumbar-sacral orthosis (L0648) provided on December 13, 2019. 
 
You asked the Plan to pay for the lumbar-sacral orthosis. You say that you would like reconsideration because 
the back brace was medically necessary. The Plan denied your request. The Plan says that the Delivery Ticket 
submitted did not include the carrier's tracking number, nor did the Proof of Delivery include an order number 
or details to corroborate the Delivery Ticket submitted. 
 
The Plan must follow Medicare rules. Medicare rules say that the supplier for all Durable Medical Equipment, 
Prosthetic, and Orthotic Supplies (DMEPOS) must have an order from the treating physician before giving any 
DMEPOS item to an enrollee. The supplier must keep the order and proof of delivery documentation on file. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the lumbar-sacral orthosis have been met. The record includes a physician order and proof of 
delivery which itemizes the supplies at issue. It is the burden of the Medicare Health Plan to substantiate the 
denial with evidence. The denial is not substantiated and we must find in your favor. Therefore, we decided 
that the Plan has to pay for lumbar-sacral orthosis (L0648) provided on December 13, 2019.  
 
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 CPT code 36589 with modifier 79 provided on January 30, 
2020. 
 
You asked the Plan to pay for CT code 36589 with modifier 79. 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 as 
billed. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
 
We looked at the file and Medicare rules. The billed CPT code, 36589, appended with modifier 79, was denied 
because a 0, 10 or 90-day post-operative procedure was not reported during its applicable post-operative 
period. Modifier 79 is used to indicate that the performance of a procedure or service during the post-operative 
period was unrelated to the original procedure. The file does not show that the original procedure or service has 
been identified. Therefore, we decided that the Plan does not have to pay for CPT code 36589 with modifier 79 
provided on January 30, 2020.