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

 
We decided that the Plan does not have to pay for laboratory services provided to the enrollee on January 20, 
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 Medicare beneficiaries are eligible for telehealth services only if they are presented from a 
covered originating site. 
 
The Plan must follow Medicare rules. Medicare rules say that for eligible telehealth services, 
telecommunications systems substitute for an in-person encounter. Medicare enrollees are eligible for 
telehealth services only if they are presented from an authorized originating site located in either a county 
outside of a Metropolitan Statistical Area (MSA) or a rural Health Professional Shortage Area (HPSA) located 
in a rural census tract. 
  
A review of the file does not show that the telehealth service was provided in an authorized originating site. 
This means that the telehealth visit is not a covered service under the Medicare program and cannot substitute 
for an in-person encounter. Consequently, the items/services ordered following the noncovered visit are 
likewise noncovered. Therefore, we decided that the Plan does not have to pay for laboratory services provided 
to the enrollee on January 20, 2020.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the provision of testing materials for home international 
normalized ratio (INR) monitoring provided on October 16, 2019 billed with code G0249. 
 
You asked the Plan to pay for the home INR monitoring materials. You say that this should be payable once 
per week as testing is done once per week. The Plan denied your request. The Plan says frequency criteria do 
not allow this to be paid more than once every 25 days. 
 
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 G0249 is Provision of test materials and equipment for 
home inr monitoring of patient with either mechanical heart valve(s), chronic atrial fibrillation, or venous 
thromboembolism who meets medicare coverage criteria; includes: provision of materials for use in the home 
and reporting of test results to physician; testing not occurring more frequently than once a week; testing 
materials, billing units of service include 4 tests. 
 
We find that CPT code G0249 is not supported in the medical record. Specifically, review of the code 
definition shows that this code reports a monthly provision of supplies for home INR monitoring. One unit is 
four tests, each of which cannot be performed more than once weekly. Since this was reimbursed on October 9, 
2019, payment for another month's supply is not supported one week later. Based on this information, we 
decided that Medicare rules for coverage of the home INR monitoring materials have not been met. Therefore, 
we decided that the Plan does not have to pay for the provision of testing materials for home international 
normalized ratio (INR) monitoring provided on October 16, 2019 billed with code G0249.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the psychiatric diagnostic evaluation (90791) rendered by the 
out of network (OON) provider on March 25, 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 psychiatric diagnostic evaluation (90791) rendered by the out of network (OON) provider 
on March 25, 2020.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab tests provided on March 18, 2020 by an out of network 
(OON) provider. 
 
You asked the Plan to pay for lab tests. 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 
there are in-network providers available for these services. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The requested provider in this case is not a network provider with the Plan. The Plan has network providers 
available who can provide the 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 tests provided on March 18, 2020 by an out of 
network (OON) provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay separately for the inpatient services provided from September 2, 
2019 to September 4, 2019. 
 
You asked the Plan to pay separately for the inpatient services. You say that the Plan should pay this claim. 
The Plan denied your request. The Plan says the claim is not payable per the 3 day or less interruption of stay 
policy. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly.  
 
We find that the enrollee was readmitted to the LTCH within 3 days of discharge so the payment is bundled 
into the payment to the LTCH. Based on this information, we decided that Medicare rules for coverage of the 
inpatient services have not been met. Therefore, we decided that the Plan does not have to pay separately for 
the inpatient services provided from September 2, 2019 to September 4, 2019.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the respiratory infectious agent detection test provided on 
April 8, 2020. 
 
You asked the Plan to pay for the testing. The Plan denied your request. The Plan says the services are not 
covered. 
 
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 pay for the testing. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found that the enrollee is an 86-year-old male with a diagnosis of fever, unspecified. A laboratory test (87633, 
respiratory infectious agent detection) was ordered. Based on the medical records provided, there is no 
documentation that the requested lab services in this case are medically reasonable and necessary. The 
provided records are inadequate to determine medical necessity of this test. 
 
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 testing have not been met. Therefore, we decided that the Plan does not have 
to pay for the respiratory infectious agent detection test provided on April 8, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an inpatient hospital stay provided from 
June 14, 2018 to June 20, 2018. 
 
You asked the Plan to waive the copayment for an inpatient hospital stay. You say that you disagree with how 
the claims were processed and billed. The Plan denied your request. The Plan says the claims were processed 
correctly and the enrollee is being charged the correct amount. 
 
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 $360 copayment for days 1-5 for inpatient hospital care.  
 
The enrollee had an inpatient hospital stay from June 14, 2018 to June 20, 2018. Therefore, the enrollee is 
responsible to pay a $360 copayment for days 1-5 (June 14, 2018 to June 18, 2018). $360 (copayment) x 5 
(inpatient days) = $1,800.  
 
The enrollee has been asked to pay the total copayment amount of $1,800 for an inpatient hospital stay. An 
inpatient hospital stay falls within the inpatient hospital care 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 inpatient hospital stay provided from June 14, 2018 to June 20, 2018.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for ground mileage (A0425) provided on September 8, 2019. 
 
You asked the Plan to pay for the ground mileage. You say that you would like reconsideration because the 
services rendered were medically necessary. The Plan denied your request. The Plan says CPT A0425 has an 
MUE value of 250, you billed 261 units. 
 
The Plan must follow Medicare rules. Medicare rules say that claims submitted where the unit of service 
exceeds the MUE value for the HCPCS/CPT code will be denied. 
 
In this case, the MUE for CPT code A0425 is 250. You billed 261 units of this code, exceeding the MUE. You 
did not bill this code with an appropriate modifier to report the same code on separate lines of a claim to enable 
the reporting of medically necessary units of service in excess of MUE. Based on this information, we decided 
that Medicare rules for coverage of the ground mileage have not been met. Therefore, we decided that the Plan 
does not have to pay for ground mileage (A0425) provided on September 8, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the subsequent nursing facility care, per day (99308, 99309) 
rendered by the out of network (OON) provider from April 1, 2020 to April 17, 2020. 
 
You asked the Plan to pay for these services. You say that you are requesting a reconsideration of the Plan's 
denial for payment. The Plan denied your request. The Plan says the services were 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 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 subsequent nursing facility care, per day (99308, 99309) rendered by the out of 
network (OON) provider from April 1, 2020 to April 17, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for physician services provided on June 18, 2020 by an out of 
network (OON) provider. 
 
You asked the Plan to pay for physician services. You say that you would like this claim reprocessed and 
approved for payment. You say that you were told that prior authorization was not obtained. The Plan denied 
your request. The Plan says prior 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 physician services provided on June 18, 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 the neuromuscular stimulator provided on April 1, 2020. 
 
You asked the Plan to pay for the neuromuscular stimulator, electronic shock unit (E0745). You say that the 
neuromuscular stimulator was medically necessary. The Plan denied your request. The Plan says the 
reasonableness of the neuromuscular stimulator was not established. 
 
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 neuromuscular stimulator, electronic 
shock unit (E0745). Our reviewer says that the neuromuscular stimulator was not medically necessary. Our 
physician reviewer found the enrollee was evaluated on January 24, 2020 for ankle pain. There is no 
documentation of a physical examination of the enrollee's feet or ankles. The enrollee was diagnosed with 
primary osteoarthritis of the right and left ankles and feet and muscle wasting of the right and left lower legs.  
The documentation in the case file does not support that the requested neuromuscular stimulator, electronic 
shock unit was medically reasonable and necessary for the enrollee in this case, as there is no documentation of 
a credible physical examination of the ankles and feet. 
 
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 neuromuscular stimulator, electronic shock unit (E0745) have not been met. 
Therefore, we decided that the Plan does not have to pay for the neuromuscular stimulator provided on April 1, 
2020.
Appeal type: Supplemental Benefit
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 December 20, 2018. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the services were not 
urgent or emergent. 
 
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 December 20, 2018.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for outpatient services provided on January 2, 2020 by an out of 
network (OON) provider. 
 
You asked the Plan to pay for outpatient 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. The 
Plan says that there is no referring provider listed. 
 
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 outpatient services provided on January 2, 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 ophthalmological services: medical examination and 
evaluation (92002) fundus photography (92250) and refraction (92015) provided June 9, 2020. 
 
You asked the Plan to pay for the vision services. You say that you feel that this was an emergency. You were 
out of state and had to get your vision checked. You were unaware that prior authorization was needed. 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. Non-emergent services with non-contracted 
providers require prior authorization before services being rendered. 
 
Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine 
vision and eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in 
this case. The Plan covers these services when rendered by an in-network provider. Non-emergent services 
with non-contracted providers require prior authorization before services being rendered.. 
 
We looked at the file and the Plan's rules. 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. Based on this information, we decided that the Plan's rules 
for coverage of the vision services have not been met. Therefore, we decided that the Plan does not have to pay 
for the ophthalmological services: medical examination and evaluation (92002) fundus photography (92250) 
and refraction (92015) provided June 9, 2020.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for comprehensive genomic profile (CGP) testing provided on 
May 4, 2020. 
 
You asked the Plan to pay for genetic testing. You say that the enrollee's treating physician ordered this testing 
to determine if there was a more effective therapy for the enrollee's condition. The Plan denied your request. 
The Plan says the denial of payment for this testing is correct, because this testing was not billed with the 
appropriate coding. 
 
The Plan must follow Medicare rules. Medicare rules say that CGP testing must be billed with CPT code 81479 
for date of service May 4, 2020.  
 
We looked at the file and Medicare rules. This testing was not billed with the appropriate coding. Based on this 
information, we decided that Medicare rules for coverage of genetic testing have not been met. Therefore, we 
decided that the Plan does not have to pay for comprehensive genomic profile (CGP) testing provided on May 
4, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the services (CPT 88189) provided on April 30, 2020.

You asked the Plan to pay for the services. The Plan denied your request. The Plan says payment for this service is included in the payment to the facility.

The Plan must follow Medicare rules. Medicare rules say that CMS does not pay any provider or supplier other than the facility or hospital for services furnished to a beneficiary. The facility or hospital must furnish all necessary covered services to the beneficiary either directly or under arrangements made with outside providers. Payment for all fees related to this service would have been included under the facility claim. Therefore, we decided that the Plan does not have to pay for the services (CPT 88189) provided on April 30, 2020.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ambulance services provided by you on April 12, 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 12, 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 provided by you on April 
12, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the high frequency chest wall oscillation device rendered on 
March 4, 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 high frequency chest wall oscillation device rendered on 
March 4, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the outpatient office visit (99214) provided on May 19, 2020 
by an out of network (OON) provider. 
 
You asked the Plan to pay for the outpatient office visit. You say that you had to move to due to 
COVID-19. Your old plan ended May 31, 2020 and the new plan began June 1, 2020 with no 
breaks in coverage so this should be covered by one of them. The Plan denied your request. The Plan says 
enrollee's must receive their medical services from an in-network provider. 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 office visit (99214) provided on 
May 19, 2020 by an out of network (OON) provider.