Persius/hicric huggingface dataset:
Appeal type: Home Health
Decision: Favorable

We decided that the Plan has to pay for the home health services provided on May 8, 2020 to May 29, 2020 billed on Type of Bill (TOB) 0322.
You asked the Plan to pay for the home health services. You say that this should be paid. The Plan denied your request. The Plan says that this was not billed with a correct TOB.
The Plan must follow Medicare rules. Medicare rules say that TOB 0322 signifies that a claim is a RAP and that partial payment should be made, which will be finalized by a claim with TOB 0329. It is noted that given the purpose of a RAP, the to and from dates used should be the same. In this case, this was billed as a RAP with TOB 0322 but a range of dates was provided. The RAP should be submitted with the first date of the episode of care filed as both the to and from dates. Then, final payment for the episode is made with the applicable date range when a claim with TOB 0329 is submitted. In this case, it cannot be verified that the TOB used is correct for the payment being requested. Therefore, we decided that the Plan has to pay for the home health services provided on May 8, 2020 to May 29, 2020 billed on Type of Bill (TOB) 0322.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an open MRI to be provided by an out of network 
(OON) provider. 
 
You asked the Plan to pre-approve an open MRI. You say that you would like the Plan to reconsider their 
denial. The Plan denied your request. The Plan says the services requested are neither emergent nor urgent to 
seek out-of-network care. The Plan says you can receive an open MRI with an in-network provider. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pre-approve care from out-of-network providers only in cases involving 
emergencies, out of area urgent care and care that cannot be provided by network providers. 
 
The requested provider in this case is not a network provider with the Plan. The Plan has network providers 
available who can provide the items/services at issue in this appeal. We found no exception that would require 
the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve 
an open MRI to be provided by an out of network (OON) provider.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay forpercutaneous vertebroplasty and vertebral augmentation procedure (22511) provided October 2, 2019.You asked the Plan to pay forpercutaneous vertebroplasty and vertebral augmentation. You say that procedure code 22511has not been paid. This is a necessary procedure. Please review and send payment.The Plan denied your request. The Plan says With the information provided, the Plan cannot 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 items and services that are not medically necessary are not covered. Multiple attempts was made by the plan to obtain the medical records from the provider without success.We looked at this the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of percutaneous vertebroplasty and vertebral augmentation have not been met.Therefore, we decided that the Plan does not have to pay forpercutaneous vertebroplasty and vertebral augmentation procedure (22511) provided October 2, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for anesthesia services provided. 
 
You asked the Plan to pay for the anesthesia services. You say that the Plan should pay this claim. The Plan 
denied your request. The Plan says the billed service cannot be verified. 
 
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 00790 is Anesthesia for intraperitoneal procedures in 
upper abdomen including laparoscopy; not otherwise specified. 
 
We find that CPT code 00790 is not supported in the medical record. Specifically, documentation supporting 
the service was not submitted. Based on this information, we decided that Medicare rules for coverage of the 
anesthesia services have not been met. Therefore, we decided that the Plan does not have to pay for anesthesia 
services provided.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the oral exam (D0120), prophylaxis (D1110), and the topical 
application of fluoride varnish (D1206) provided on July 9, 2020. 
 
You asked the Plan to pay for the dental services. You say that you and your husband had back to back 
appointments with the same dentist. You say that since that dentist was with another patient, you had to see 
another dentist instead. The Plan denied your request. The Plan says the dentist in this case is not a network 
provider. The Plan also says services that you receive out of network are not covered. 
 
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 when you receive them out of network. Therefore, we decided that the 
Plan does not have to pay for the oral exam (D0120), prophylaxis (D1110), and the topical application of 
fluoride varnish (D1206) provided on July 9, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for injection, milrinone lactate (J2260 108 units) supplies for 
maintenance of non-insulin drug infusion catheter, per week (A4221 2 units) infusion supplies for external drug 
infusion pump, per cassette or bag (A4222 3 units) and injection, milrinone lactate (J2260-JW, 2 units) 
provided July 21, 2019 to July 29, 2019. 
 
You asked the Plan to pay for the injection/infusion supplies. You say that you sent in the delivery ticket with 
the records as is standard protocol. See them again below for processing. The Plan denied your request. The 
Plan says the records do not support the service billed. 
 
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 or an itemized shipping/billing invoice to indicate the 
specific supplies provided in this case. 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 
injection, milrinone lactate (J2260 108 units) supplies for maintenance of non-insulin drug infusion catheter, 
per week (A4221 2 units) infusion supplies for external drug infusion pump, per cassette or bag (A4222 3 
units) and injection, milrinone lactate (J2260-JW, 2 units) provided July 21, 2019 to July 29, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the medical eye exam you had with an 
ophthalmologist on July 27, 2020. 
 
You asked the Plan to waive the copayment for the ophthalmology exam. You say that you did not have to pay 
a copayment for this service last year even though it was coded the same way. The Plan denied your request. 
The Plan says you were charged this copayment 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 $30 
copayment for medical eye exams.  
 
You have been asked to pay a $30 copayment for the ophthalmology exam. This copayment applies regardless 
of what you were charged in previous years. This means that you have been asked to pay the correct amount 
based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you 
enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for the medical 
eye exam you had with an ophthalmologist on July 27, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay forthe biological materials and osseous, osteoperiosteal, or cartilage graft provided on February 27, 2020.You asked the Plan to pay forthe biological materials and osseous, osteoperiosteal, or cartilage graft. You say that you submitted the pre-operative x-ray forconsideration. You say that The Plan denied your request. The Plan says the services are not covered benefits.Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case.Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not among those covered under this benefit.Therefore, we decided that the Plan does not have to pay forthe biological materials and osseous, osteoperiosteal, or cartilage graft provided on February 27, 2020.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the surgical services (15120, 11626) provided on June 18, 
2019, by an out of network (OON) provider. 
 
You asked the Plan to pay for the surgical services. 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 by the 
facility or the provider; therefore, payment has been correctly denied. 
 
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 surgical services (15120, 11626) provided on 
June 18, 2019, by an out of network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the periodic oral evaluation, intraoral x-ray and prophylaxis 
provided on May 27, 2020. 
 
You asked the Plan to pay for the periodic oral evaluation, intraoral x-ray and prophylaxis. You say that there is 
no provider close to you that is an approved provider. You say that you still have coverage and the claim 
should be reconsidered. The Plan denied your request. The Plan says payment cannot be issued for services 
performed by a provider that has opted out of Medicare. 
 
The Plan must follow Medicare rules. The rules say that no Medicare payment may be made to a beneficiary 
for items or services provided directly by a physician or practitioner who has opted out of the program except 
in cases involving emergencies or urgently needed care. 
 
The services at issue in this appeal were provided in a non-urgent, non-emergent situation by the provider. This 
provider has opted out of the Medicare program. Therefore, we decided that the Plan does not have to pay for 
the periodic oral evaluation, intraoral x-ray and prophylaxis provided on May 27, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay forthe laboratory services rendered on May 29, 2020.You asked the Plan to pay fortheseservices. You say that you disagree with the denial.The Plan denied your request. The Plan says procedure codes 80157, 80177, 80201, 80162, 80159 and 80173 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.We find that CPT codes 80157, 80177, 80201, 80162, 80159 and 80173 are not supported in the medical record. Specifically, there is no documentation of testing on blood specimens. 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 forthe laboratory services rendered on May 29, 2020.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a home visit (99349) provided on July 30, 2019. 
 
You asked the Plan to pay for the home visit. You say that you would like reconsideration because the services 
rendered were medically necessary. The Plan denied your request. The Plan says the billed code does not 
appropriately reflect the services provided by the resident nurse. 
 
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 99349 is home visit for the evaluation and management 
of an established patient, which requires at least 2 of these 3 key components: A detailed interval history; A 
detailed examination; Medical decision making of moderate complexity. Counseling and/or coordination of 
care with other physicians, other qualified health care professionals, or agencies are provided consistent with 
the nature of the problem(s) and the patient's and/or family's needs. Usually, the presenting problem(s) are 
moderate to high severity. Typically, 40 minutes are spent face-to-face with the patient and/or family.  
 
We find that CPT code 99349 is not supported in the record. Specifically, the record does not indicate that the 
physician was present in the member's home. Based on this information, we decided that Medicare rules for 
coverage of the home visit have not been met. Therefore, we decided that the Plan does not have to pay for a 
home visit (99349) provided on July 30, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment forthe tick removal procedure (code 10120) you received at a clinic that is part of an outpatient hospital facility on June 5, 2020.You asked the Plan to waive the copayment forthe tick removal procedure. You say that if you had known this service would be considered surgery, you wouldn't have had it done.The Plan denied your request. The Plan says you were charged this copayment 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 $200 copayment for surgery in an outpatient hospital facility. You have been asked to pay a $200 copayment for the tick removal procedure. The tick removalprocedure falls within the surgery in an outpatient hospital facility benefit category. Medicare considers the code billed for this service (10120) to be a surgical service.  In addition, this surgical service was performed in a clinic portion of an outpatient hospital facility. 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 tick removal procedure (code 10120) you received at a clinic that is part of an outpatient hospital facility on June 5, 2020.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for wound care services provided on October 3, 2019. 
 
You asked the Plan to pay for the wound care services (14301). You say that the Plan should pay this claim. 
The Plan denied your request. The Plan says this is a duplicate claim. 
 
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.  
 
We find that CPT code 14301 is a duplicate claim. Based on this information, we decided that Medicare rules 
for coverage of the wound care services have not been met. Therefore, we decided that the Plan does not have 
to pay for wound care services provided on October 3, 2019.
Appeal type: Hospice
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services provided on November 15, 2019. 
 
You asked the Plan to pay for the laboratory services. You say that the enrollee was not enrolled in hospice at 
the time of services. The Plan denied your request. The Plan says the enrollee's claim would be covered under 
Original Medicare as it is responsible for coverage of Part B benefits starting on the date of election until the 
last day of the month in which hospice is revoked. The Plan also says it is the provider's responsibility to verify 
the member's coverage before rendering services and to know proper billing procedures for a Medicare 
Advantage member on hospice. 
 
Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice 
services. Medicare hospice pays for claims related to the terminal illness. The rules say that the Plan may direct 
the provider to bill Medicare directly for these services.  
 
The enrollee was under the Medicare hospice benefit for the dates of service at issue in this appeal. Therefore, 
we decided that the Plan does not have to pay for the laboratory services provided on November 15, 2019.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services provided on June 9, 2020, by an out 
of network (OON) provider. 
 
You asked the Plan to pay for the laboratory services. 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 by the 
facility or the provider; therefore, payment has been correctly denied. 
 
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 laboratory services provided on June 9, 2020, 
by an out of network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the anesthesia services (01402, 62322 and 64447) provided 
on August 12, 2019.  
 
You asked the Plan to pay for the anesthesia services. You say that you would like reconsideration because 
these services were denied in error. The Plan denied your request. The Plan says the documentation submitted 
does not support the services billed. 
 
The Plan must follow Medicare rules. Medicare rules say that for Medicare to consider coverage and payment 
for any item or service, the information submitted by the supplier or provider must corroborate the 
documentation in the beneficiary's medical documentation and confirm that Medicare coverage criteria have 
been met. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the anesthesia services have not been met. Specifically, the record does not include any clinical 
documentation. There is insufficient information to determine whether payment is due or the amount of 
payment. Therefore, we decided that the Plan does not have to pay for the anesthesia services (01402, 62322 
and 64447) provided on August 12, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for a blood glucose monitor (E0607) and calibrator chips 
(A4256) provided on May 19, 2020, through August 6, 2020. 
 
You asked the Plan to pay for the diabetic testing supplies. You say that you would like reconsideration 
because the supplies are medically necessary. The Plan denied your request. The Plan says the documentation 
submitted does not include a valid physician order or proof of delivery. 
 
The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when there are both a 
physician order and proof of delivery.  
 
The record does not contain a valid physician order for the supplies provided in this case. Of note, the 
physician order submitted is dated January 14, 2019. Medicare requires that for high utilization, the treating 
practitioner must verify adherence to the high utilization testing regimen. 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 a blood glucose monitor (E0607) and calibrator chips (A4256) provided on May 19, 
2020, through August 6, 2020.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for cardiac device monitoring (93298, G2066) 
provided June 9, 2020. 
 
You asked the Plan to waive the copayment for the cardiac device monitoring. You say that the copayment 
should be waived. The Plan denied your request. The Plan says the correct copayment 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 $50 
copayment for diagnostic testing.  
 
You have been asked to pay a $50 copayment for the cardiac device monitoring. The cardiac device monitoring 
falls within the diagnostic testing 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 
cardiac device monitoring (93298, G2066) provided June 9, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for Incrediwear elastic stockings provided on May 17, 2020. 
 
You asked the Plan to pay for elastic stockings. You say that these knee sleeves were part of the treatment 
process to prevent fluid build-up in your knees. The Plan denied your request. The Plan says the denial of 
payment for these items is correct, because these elastic stockings are not covered by Medicare. 
 
The Plan must follow Medicare rules. Medicare rules say that elastic stockings are not covered by Medicare.  
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of elastic stockings have not been met. Therefore, we decided that the Plan does not have to pay for 
Incrediwear elastic stockings provided on May 17, 2020.