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

 
We decided that the Plan has to pay for total knee arthroplasty, assistant provided on January 23, 2020. 
 
You asked the Plan to pay for the surgical assist service. You say that the service was performed by an assistant 
physician. The Plan denied your request. The Plan says that the service is not supported in the records. 
 
The Plan follows Medicare rules. Medicare rules say that items and services that are not medically necessary 
are not covered. Medicare makes payment for an assistant at surgery when the procedure is authorized for an 
assistant and the person performing the service is a physician.  
 
We looked at the file and Medicare rules. Assistant at surgery services are those services rendered by 
physicians or non-physician practitioners who actively assist the physician in charge of performing a surgical 
procedure. The medical note confirms this provider assisted in the arthroplasty. Based on this 
information, we decided that Medicare rules for coverage of the surgical assist service have been met. 
Therefore, we decided that the Plan has to pay for total knee arthroplasty, assistant provided on January 23, 
2020.
Appeal type: Practitioner Services
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 May 1, 2020. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the services were 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 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 May 1, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for knee orthoses (L1851), lumbar-sacral orthosis (L0650) and 
additions (L2397) provided on March 17, 2020. 
 
You asked the Plan to pay for the orthoses. You say that you would like reconsideration because these supplies 
were medically necessary. The Plan denied your request. The Plan says there is no evidence of an established 
relationship between the member and ordering physician. 
 
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 knee orthoses (L1851), 
lumbar-sacral orthosis (L0650) and additions (L2397) provided on March 17, 2020.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for portable x-ray services (R0075) provided September 25, 
2019. 
 
You asked the Plan to pay for the portable x-ray services. You say that the services were medically necessary. 
The Plan denied your request. The Plan says the claim included an invalid modifier. 
 
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 R0075 is not supported in the medical record. Specifically, CPT code R0075 has a 
Professional Component (PC)/Technical Component (TC) indicator of 3 per 2019 National Physician Fee 
Schedule. Modifiers 26 and TC cannot be used with these codes. Based on this information, we decided that 
Medicare rules for coverage of the portable x-ray services have not been met. Therefore, we decided that the 
Plan does not have to pay for portable x-ray services (R0075) provided September 25, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the lumbar-sacral orthosis, the ankle foot orthosis, the knee 
orthoses and suspension sleeves, and heel stabilizer provided on February 19, 2020. 
 
You asked the Plan to pay for the lumbar-sacral orthosis (L0650), the ankle foot orthosis (L1971), the knee 
orthoses (L1851) and suspension sleeves (L2397), and heel stabilizer (L3170). You say that the orthoses were 
medically necessary. The Plan denied your request. The Plan says the documentation did not contain evidence 
of a relationship 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 noncovered visit are 
likewise noncovered. Therefore, we decided that the Plan does not have to pay for the lumbar-sacral orthosis, 
the ankle foot orthosis, the knee orthoses and suspension sleeves, and heel stabilizer provided on February 19, 
2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for inpatient mental health treatment provided December 6, 2019 
to February 6, 2020. 
 
You asked the Plan to pay for the inpatient mental health treatment. 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 inpatient psychiatric services may be covered if the 
patient requires active treatment.  
 
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 inpatient mental health treatment. Our 
reviewer says that the inpatient level care was not medically necessary. Our physician reviewer found the 
enrollee does not meet the criteria for continued acute inpatient mental health treatment for the dates in 
question as this enrollee was not shown to be a danger to herself or others. She was not showing any auditory 
or visual hallucinations and was cooperative and compliant with treatment. 
 
 
 
 
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 inpatient mental health treatment have not been met. Therefore, we decided 
that the Plan does not have to pay for inpatient mental health treatment provided December 6, 2019 to February 
6, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the wound care supplies provided on December 20, 2019. 
 
You asked the Plan to pay for skin barrier(A5120), adhesive remover (A4456), and housing and integrated 
adhesive (A7508). You say that the Plan should pay this claim. The Plan denied your request. The Plan says 
there is no itemized delivery ticket to indicate what specific supplies were provided and the physician order is 
dated after the date of service. 
 
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 and proof of delivery for the supplies provided in this case. 
The physician order is dated May 19, 2020 and there is no itemized invoice. 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 the wound care supplies provided on December 20, 2019.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for surgical assistant services on a prostatectomy (55831) 
provided by a registered nurse first assistant (RNFA) on December 2, 2019. 
 
You asked the Plan to pay for surgical assistant services. You say that this should be paid at the in-network 
rate. The Plan denied your request. The Plan says these services are not covered when provided by a RNFA. 
 
The Plan follows Medicare rules. The rules say that Medicare only pays for assistant surgery services when the 
procedure is covered for an assistant and the person who assists the surgery bears the designation of a 
physician, PA, NP, or CNS. 
 
In this case, the record does not show that the provider of the surgical assistant service is a physician, PA, NP, 
or CNS. Medicare only makes payment for surgical assistant services when provided by one of these types of 
practitioners. Therefore, we decided that the Plan does not have to pay for surgical assistant services on a 
prostatectomy (55831) provided by a registered nurse first assistant (RNFA) on December 2, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for orthotics (L1971, L3170, L0650, L1851, L2397, L3916) 
provided on 
 
You asked the Plan to pay for orthotics. You say that these items should be covered. The Plan denied your 
request. The Plan says the submitted documentation does not include a valid 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 proof of delivery for the supplies provided in this case. The proof of 
delivery does not corroborate the billed date of service. 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 orthotics (L1971, L3170, L0650, L1851, L2397, L3916) provided on
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for ankle foot orthosis (L1971), a plastic foot (L3170), lumbar-
sacral orthosis (L0648), knee orthosis (L1851), shoulder elbow wrist hand orthosis (L3960), wrist hand orthosis 
(L3916) and a suspension sleeve (L2397) provided on March 23, 2020. 
 
You asked the Plan to pay for the durable medical equipment. You say that you would like reconsideration 
because this equipment is medically necessary. The Plan denied your request. The Plan says the documentation 
submitted did not include an itemized billing/shipping invoice to indicate the specific supplies or proof of 
delivery for the billed date of service. 
 
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 
record does not include an itemized shipping/billing invoice to verify the supplies billed. Additionally, the 
delivery ticket is for a different date of service 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 ankle foot orthosis (L1971), a plastic foot (L3170), lumbar-sacral orthosis (L0648), 
knee orthosis (L1851), shoulder elbow wrist hand orthosis (L3960), wrist hand orthosis (L3916) and a 
suspension sleeve (L2397) provided on March 23, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the services (CPT 99190) provided on March 2, 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 Part A DRG 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 99190) provided on March 2, 
2020.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the services (CPT 85060) provided on April 21, 2020. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the services were 
billed incorrectly. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
We find that CPT code 85060 is not supported in the medical record. Specifically, this code cannot be paid if 
provided to hospital outpatient or non-hospital patients. The services in question were billed with a place of 
service of 22, outpatient hospital. Based on this information, we decided that Medicare rules for coverage of 
the services have not been met. Therefore, we decided that the Plan does not have to pay for the services (CPT 
85060) provided on April 21, 2020.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory testing provided on March 3, 2020. 
 
You asked the Plan to pay for the laboratory testing. You say that you would like the plan to reconsider their 
denial. The Plan denied your request. The Plan says the services provided are not a covered benefit. 
 
The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few 
tests listed above, are not covered. 
 
The laboratory testing at issue in this appeal, the laboratory testing, was requested solely for screening 
purposes. Medicare does not cover this test solely for screening purposes. Therefore, we decided that the Plan 
does not have to pay for the laboratory testing provided on March 3, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for foot orthotics. 
 
You asked the Plan to pay for foot orthotics. You say that foot orthotics were covered in the past. The Plan 
denied your request. The Plan says this item is not a covered benefit. 
 
Medicare rules state that supportive devices for the feet (such as orthotics) are only covered for patients with 
diabetic foot disease or for patients who wear a leg brace. The Plan follows these same rules.   
 
Records show that you do not suffer from diabetic foot disease and you do not wear a leg brace. Although 
orthotics may be appropriate for you, neither Medicare nor the Plan provides coverage of orthotics for your 
condition. Therefore, we decided that the Plan does not have to pay for foot orthotics.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the domiciliary or rest home visit (99335) rendered by the 
out of network (OON) provider on March 17, 2020. 
 
You asked the Plan to pay for this service. You say that you are requesting a reconsideration of the Plan's 
denial for payment. The Plan denied your request. The Plan says the service was rendered by an out of network 
provider, without prior authorization. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The provider in this case is not a network provider with the Plan. The Plan has network providers available 
who can provide the service at issue in this appeal. The Plan did not pre-approve the service at issue. We found 
no exception that would require the Plan to pay for this service. Therefore, we decided that the Plan does not 
have to pay for the domiciliary or rest home visit (99335) rendered by the out of network (OON) provider on 
March 17, 2020.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for ambulance services (A0429) provided April 6, 2020. 
 
You asked the Plan to pay for the ambulance services. You say that the services were medically necessary. The 
Plan denied your request. The Plan says the claim was not billed with the proper modifier. 
 
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 A0429 is not supported in the medical record. Specifically, the enrollee died after 
ambulance dispatch but prior to being loaded in the ambulance. A "QL" modifier is required in this instance 
and was not included on the claim submitted. Based on this information, we decided that Medicare rules for 
coverage of the ambulance services have not been met. Therefore, we decided that the Plan does not have to 
pay for ambulance services (A0429) provided April 6, 2020.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for the breast ultrasound (76641) provided on 
September 20, 2019. 
 
You asked the Plan to waive the coinsurance 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 coinsurance 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 20% 
coinsurance for other diagnostic procedures and tests such as MRIs, PET scans, CT scans, and other nuclear 
medicine.  
 
You have been asked to pay $31.64 ($158.19 allowed amount x 20% coinsurance) for the diagnostic ultrasound 
provided. The record shows that this ultrasound was ordered by the referring physician as a diagnostic 
screening due to dense breast tissue and a history of abnormal lymph nodes. 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 the breast ultrasound (76641) provided on September 20, 2019.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the expanded pharmacogenomic panel provided on April 24, 
2019. 
 
You asked the Plan to pay for the expanded pharmacogenomic panel. You say that you would like the Plan to 
reconsider their denial of payment. The Plan denied your request. The Plan says the services are not covered. 
 
The Plan must follow Medicare rules. Medicare rules say that CYP gene panels are not covered.  
 
We looked at the file and Medicare rules. In this case, the file shows you billed for an expanded 
pharmacogenomic panel. These panels should be billed with a single code - CPT 81479. CYP gene panels that 
test for multiple CYP genes are not covered by Medicare. Based on this information, we decided that Medicare 
rules for coverage of the expanded pharmacogenomic panel have not been met. Therefore, we decided that the 
Plan does not have to pay for the expanded pharmacogenomic panel provided on April 24, 2019.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pay for therapeutic activities (97530) provided on January 22, 2020. 
 
You asked the Plan to pay for the therapeutic activities. You say that you would like reconsideration based on 
the records submitted. The Plan denied your request. The Plan says this code was billed without the required 
modifier. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly.  
 
We find that CPT code 97530 is not supported in the medical record. Specifically, CPT code 97530 was not 
billed with the required GN, GO or GP modifier. Based on this information, we decided that Medicare rules for 
coverage of the therapeutic activities have not been met. Therefore, we decided that the Plan does not have to 
pay for therapeutic activities (97530) provided on January 22, 2020.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services provided from March 2, 2020 to 
March 6, 2020. 
 
You asked the Plan to pay for the laboratory services. You say that you would like the Plan to reconsider their 
denial of payment. The Plan denied your request. The Plan says the services are not covered. 
 
The Plan must follow Medicare rules. Medicare rules say that a physician order is not required to be signed, 
however, the physician must clearly document, in the medical record, his or her intent that the test be 
performed. 
 
We looked at the file and Medicare rules. We find that payment for the lab services is not supported in the 
medical record. We find that the issue of intent is not clear. There are no medical records in the case file in 
regards to the physician's intent that the test be performed prior to services taking place. Therefore, we decided 
that the Plan does not have to pay for the laboratory services provided from March 2, 2020 to March 6, 2020.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services provided on December 11, 2019 by 
an out of network (OON) provider. 
 
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says the services were rendered by an out-of-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 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 December 11, 
2019 by an out of network (OON) provider.