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

 
We decided that the Plan does not have to adjust the copayment for the chest x-ray (71046) provided on  
April 25, 2020. 
 
You asked the Plan to adjust the copayment for this service. You say that you are requesting a reconsideration 
of the Plan's denial. 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). Your contract with the Plan clearly says that you must pay a $95 
copayment for basic radiological services provided at an in-network outpatient hospital.  
 
You have been asked to pay a $75.31 copayment for the basic radiological service provided at an in-network 
outpatient hospital. This is the Plan allowed amount, which is less than the applicable copayment. This means 
that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a 
contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan 
does not have to adjust the copayment for the chest x-ray (71046) provided on April 25, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a specialist visit provided on March 16, 
2020. 
 
You asked the Plan to waive the copayment for a specialist visit. You say that you do not believe you should be 
billed for this service. 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 $20 
copayment for services obtained from an in-network specialist.  
 
You have been asked to pay a $20 copayment for a specialist visit. A specialist visit falls within the 
physician/practitioner services, including doctor?s office visits 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 specialist visit provided on March 16, 2020.  
 
Your complaint about feeling that your doctor prescribed you medication you believed would not work is not a 
valid appeal for medical coverage. This part of your complaint is a grievance that must be answered by the 
Plan. Medicare does not permit us to make a decision about these types of complaints.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an x-ray of the wrist (73110) provided October 8, 2019. 
 
You asked the Plan to pay for the x-ray. You say that the services were medically necessary. The Plan denied 
your request. The Plan says the records provided do not support the services billed. 
 
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 73110 is Radiologic Exam, Wrist, minimum of 3 views. 
 
We find that CPT code 73110 is not supported in the medical record. Specifically, the record does not show 
how many views were taken. Based on this information, we decided that Medicare rules for coverage of the x-
ray have not been met. Therefore, we decided that the Plan does not have to pay for an x-ray of the wrist 
(73110) provided October 8, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the domiciliary or rest home visit (99337) and the chronic care management services (99490) rendered on February 29, 2020 and March 3, 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.

You are 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 domiciliary or rest home visit (99337) and the chronic care management services (99490) rendered on February 29, 2020 and March 3, 2020.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan does not have to pay for psychotherapy services that you provided on May 4, 2020. 
You asked the Plan to pay for the psychotherapy services. The Plan denied your request. The Plan says this 
provider type is not eligible to enroll in the Medicare program. 
The Plan must follow Medicare rules. Medicare rules say that a Licensed Professional Counselor is not eligible 
to participate in the Medicare program. 
We looked at the file and Medicare rules. The provider at issue is a Licensed Professional Counselor. A 
Licensed Professional Counselor is not eligible to participate in the Medicare program. Therefore, we decided 
that the Plan does not have to pay for psychotherapy services that you provided on May 4, 2020.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the subsequent nursing facility care provided on May 12, 
2020 by an OON provider. 
 
You asked the Plan to pay for the subsequent nursing facility care. You say that the treating provider depends 
upon the hospital staff to verify eligibility, and to obtain the proper authorization from the enrollee's insurance 
company. You also say that the treating physician provided medically necessary services to the enrollee in 
good faith. The Plan denied your request. The Plan says prior authorization was not obtained by the provider or 
facility. The Plan also says that services rendered by OON providers require prior authorization. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The requested provider in this case is not a network provider with the Plan. The Plan 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 subsequent nursing facility care provided on 
May 12, 2020 by an OON provider.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pay for skilled nursing facility (SNF) services provided March 20, 
2020 to April 18, 2020. 
 
You asked the Plan to pay for SNF services. You say that the services were medically necessary. The Plan 
denied your request. The Plan says coverage criteria was not met. 
 
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 pay for SNF services. Our reviewer says that daily 
skilled services are not necessary. Our physician reviewer found the enrollee did not meet severity of illness or 
intensity of service criteria for an inpatient basis in a skilled nursing facility 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 SNF services have not been met. Therefore, we decided that the Plan does not 
have to pay for skilled nursing facility (SNF) services provided March 20, 2020 to April 18, 2020.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the laboratory services to be provided by an out of 
network (OON) provider. 
 
You asked the Plan to pre-approve these OON services. You say that you would like the plan to reconsider 
their denial. The Plan denied your request. The Plan says the services rendered are not a covered benefit. 
 
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 
the laboratory services to be provided by an out of network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the drug testing coded 80307 provided on April 3, 2020. 
 
You asked the Plan to pay for the drug testing. You say that you would like the plan to reconsider their denial. 
The Plan denied your request. The Plan says the services billed are not supported by the documentation. 
 
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 80307 is drug test(s), presumptive, any number of drug 
classes, any number of devices or procedures; by instrument chemistry analyzers (e.g., utilizing immunoassay 
[e.g., EIA, ELISA, EMIT, FPIA, IA, KIMS, RIA]), chromatography (e.g., GC, HPLC), and mass spectrometry 
either with or without chromatography, (e.g., DART, DESI, GC-MS, GC-MS/MS, LC-MS, LC-MS/MS, 
LDTD, MALDI, TOF) includes sample validation when performed, per date of service. 
 
We find that CPT code 80307 is not supported in the medical record. Specifically, the place of service on the 
CMS-1500 form line 24B must reflect the location of the patient when the specimen was obtained. The 
submitted claim form indicates the laboratory specimen was obtained in a laboratory, place of service 81; 
however, the claim history indicates that the specimen was obtained in an office setting place of service 11. 
Based on this information, we decided that Medicare rules for coverage of the drug testing have not been met. 
Therefore, we decided that the Plan does not have to pay for the drug testing coded 80307 provided on April 3, 
2020.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pay for home infusion therapy (S9328) provided on February 13, 
2020. 
 
You asked the Plan to pay for the home infusion therapy. You say that you would like reconsideration because 
this is not durable medical equipment and was not delivered to the member's home. The Plan denied your 
request. The Plan says S codes are not payable by Medicare. 
 
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 code S9328 is not supported in the record. Specifically, per the Physician Fee Schedule, CPT 
code S9328 has a status indicator of I. This means that CPT code S9328 is not valid for Medicare purposes. 
Based on this information, we decided that Medicare rules for coverage of the home infusion therapy have not 
been met. Therefore, we decided that the Plan does not have to pay for home infusion therapy (S9328) 
provided on February 13, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the continued rental of a powered pressure-reducing air 
mattress (E0277) provided 01/18/2019 to 04/19/2019. 
 
You asked the Plan to pay for a powered pressure-reducing air mattress. You say that you have received a bill. 
Please help resolve it. The Plan denied your request. The Plan says under Medicare guidelines, this request 
does not meet the not medically necessary criteria. 
 
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 a powered pressure-reducing air mattress. 
Our reviewer says that the requested items/services are not considered medically reasonable and necessary in 
this case. Our physician reviewer found the review has determined that the request does not meet the 
requirements listed in the LCD for Medicare coverage. In this case, there is no documentation in the medical 
record to show that: (1) other aspects of the care plan are being modified to promote healing, or (2) the use of 
the group 2 support surface is reasonable and necessary for wound management. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of a powered pressure-reducing air mattress have not been met. Therefore, we 
decided that the Plan does not have to pay for the continued rental of a powered pressure-reducing air mattress 
(E0277) provided 01/18/2019 to 04/19/2019.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for assembly and operation of pump with oxygenator or heat 
exchanger provided on March 6, 2020. 
 
You asked the Plan to pay for the special pump services. You say that this equipment was provided to the 
enrollee during an inpatient stay and should be covered. The Plan denied your request. The Plan says this claim 
cannot be paid separately based on Medicare guidelines for inpatient services. 
 
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.  
 
This equipment was used during a surgical procedure by the facility. Payment for this service would have been 
included under the facility claim. Payment to you for this service is the responsibility of the facility or hospital. 
Based on this information, we decided that Medicare rules for coverage of special pump services have not been 
met. Therefore, we decided that the Plan does not have to pay for assembly and operation of pump with 
oxygenator or heat exchanger provided on March 6, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for therapeutic continuous glucose monitor (CGM) supply 
allowance (K0553) provided March 29, 2020. 
 
You asked the Plan to pay for therapeutic CGM supply allowance. You say that please kindly review the 
attached guidelines and also medical records showing the medical necessity for the billed diagnosis. The Plan 
denied your request. The Plan says the billed supply code cannot be verified 
 
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, and deliver ticket or relevant medical records which 
support medical necessity for the supplies provided in this case.  The delivery ticket submitted did not include 
the carrier's tracking number, the proof of delivery did not include an order number or details to corroborate the 
delivery ticket submitted. The proof of delivery is not itemized to indicate the specific supplies. 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 therapeutic continuous glucose monitor (CGM) supply 
allowance (K0553) provided March 29, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the neuromuscular stimulator, electronic shock unit (E0745) 
Shoulder elbow wrist hand orthosis (L3960) provided April 1, 2020. 
 
You asked the Plan to pay for the orthosis and electrical shock unit. You say that please review the attached 
medical records. The Plan denied your request. The Plan says there is no actual physical exam. All information 
was provided over the phone. The enrollee is not eligible for telehealth services. There is no evidence of an 
established relationship between the enrollee and the ordering physician, there was no claims submitted for an 
evaluation and management service and there is no evidence of a prior telehealth service with the ordering 
physician as required per CMS guidelines. 
 
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 non-covered visit are 
likewise non-covered. Therefore, we decided that the Plan does not have to pay for the neuromuscular 
stimulator, electronic shock unit (E0745) Shoulder elbow wrist hand orthosis (L3960) provided April 1, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a domiciliary, rest home visit provided on October 23, 2019. 
 
You asked the Plan to pay for the domiciliary, rest home visit. The Plan denied your request. The Plan says 
non-emergent, non-urgent services with out-of-network providers require prior authorization. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The requested provider in this case is not a network provider with the Plan. The Plan 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 a domiciliary, rest home visit provided on October 23, 2019.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the drug tests (G0480, G0482) and the laboratory services  
(80307, 82542, 83789, 80299) rendered by the out of network (OON) provider from October 9, 2019 to 
December 30, 2019. 
 
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 drug tests (G0480, G0482) and the laboratory services (80307, 82542, 83789, 
80299) rendered by the out of network (OON) provider from October 9, 2019 to December 30, 2019.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an ultrasound of the breast (76642) 
performed on March 24, 2020. 
 
You asked the Plan to waive the copayment for an ultrasound of the breast. You say that you should not be 
charged for a mammogram administered as a consequence of a routine physical. 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 $300 
copayment for diagnostic radiology other than CT scans.  
 
You have been asked to pay a $50 copayment for an ultrasound of the breast. An ultrasound of the breast falls 
within the "Outpatient diagnostic tests and therapeutic services and supplies" benefit category. This means that 
you have been asked to pay less than the full 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 ultrasound of the breast (76642) performed on March 24, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the assembly and operation of a pump (99190) provided on 
November 18, 2019. 
 
You asked the Plan to pay for the pump assembly and operation. You say that you would like reconsideration 
because it takes 30 minutes to set up the machine and the perfusionist is required to remain in the operating 
room throughout the length of the procedure. The Plan denied your request. The Plan says payment for this 
service is included in the DRG payment to the facility. 
 
The Plan must follow Medicare rules. Medicare rules say that Medicare does not pay any provider or supplier 
other than the facility or hospital for services furnished to the beneficiary while an inpatient. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the pump assembly and operation have not been met. Specifically, payment for this service is 
included in the DRG payment to the facility and is the responsibility of the facility to any vendor. Therefore, 
we decided that the Plan does not have to pay for the assembly and operation of a pump (99190) provided on 
November 18, 2019.