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

 
We decided that the Plan does not have to pay for external ocular photography with interpretation and report 
(92285) provided on January 6, 2020. 
 
You asked the Plan to pay for the external ocular photography. You say that you would like reconsideration 
based on the records submitted. The Plan denied your request. The Plan says the documentation does not 
support the service 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 92285 is external ocular photography with interpretation 
and report for documentation of medical progress (eg, close-up photography, slit lamp photography, 
goniophotography, stereo-photography). 
 
We asked our coder 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 external ocular photography. Our reviewer says that CPT 
code 92285 does not meet criteria for billing or reimbursement consideration. Our reviewer found the operative 
report does not include documentation of interpretation and report to verify procedure performed. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the external ocular photography have not been met. Therefore, we decided that 
the Plan does not have to pay for external ocular photography with interpretation and report (92285) provided 
on January 6, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a lumbar-sacral orthosis (L0650) provided to the enrollee on 
January 17, 2020. 
 
You asked the Plan to pay for the orthosis. You say that the claim should be paid. The Plan denied your 
request. The Plan says the documentation does not indicate services are necessary for treatment of the 
enrollee's condition. 
 
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 a lumbar-sacral orthosis 
(L0650) provided to the enrollee on January 17, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for A TENS unit (E0745) provided to the enrollee on April 12, 
2020. 
 
You asked the Plan to pay for the neuroelectric stimulator. You say that the claim should be paid. The Plan 
denied your request. The Plan says the documentation does not indicate services are necessary for treatment of 
the enrollee's condition. 
 
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 A TENS unit (E0745) 
provided to the enrollee on April 12, 2020.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for tissue transfer (14301) provided on March 9, 2020. 
 
You asked the Plan to pay for tissue transfer. You say that this is supported. The Plan denied your request. The 
Plan says this is not documented as a separate procedure. 
 
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 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 tissue transfer. Our reviewer says that the 
use of this code is not supported by the records. Our physician reviewer found the medical records provided do 
not include documentation of an adjacent tissue transfer or rearrangement, any area; defect 30.1 sq cm to 60.0 
sq cm being performed on March 9, 2020, therefore this service cannot be verified. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of tissue transfer have not been met. Therefore, we decided that the Plan does not 
have to pay for tissue transfer (14301) provided on March 9, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for supplies for a continuous glucose monitor (K0553) provided 
March 6, 2020. 
 
You asked the Plan to pay for the supplies. You say that these items were medically necessary. The Plan denied 
your request. The Plan says the documents provided do not support the items 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. The delivery ticket provided is not itemized and does not 
detail what items were delivered. 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 supplies for a 
continuous glucose monitor (K0553) provided March 6, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for nursing facility discharge day management over 30 minutes 
(99316) provided July 1, 2019. 
 
You asked the Plan to pay for nursing facility discharge day management. You say that the records provided 
should support the necessity of the service in dispute. The Plan denied your request. The Plan says the records 
do not support the billed service. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
In this case, the CPT Code Manual definition of code 99316 is nursing facility discharge day management over 
30 minutes.  
 
We find that CPT code 99316 is not supported in the medical record. Specifically, the submitted discharge 
summary does not support nursing facility discharge day management of more than 30 minutes was performed. 
A documented duration of time of 31 minutes or more is required to support this code for the billed date of 
service. Based on this information, we decided that Medicare rules for coverage of nursing facility discharge 
day management have not been met. Therefore, we decided that the Plan does not have to pay for nursing 
facility discharge day management over 30 minutes (99316) provided July 1, 2019.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the medical services provided to the enrollee by an out-of-
network provider on June 9, 2020. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the services are 
available in-network. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The requested provider in this case is not a network provider with the Plan. The Plan has network providers 
available who can provide the services at issue in this appeal. The Plan did not pre-approve the services at 
issue. We found no exception that would require the Plan to pay for these services. Therefore, we decided that 
the Plan does not have to pay for the medical services provided to the enrollee by an out-of-network provider 
on June 9, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for specialist services provided by a 
participating provider on March 17, 2020 to May 5, 2020. 
 
You asked the Plan to waive the copayment for specialist services. You say that you thought copayments were 
waived during the pandemic. The Plan denied your request. The Plan says the correct copayment has been 
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 $40 
copayment for physician/practitioner services/specialist visit.  
 
You have been asked to pay a $40 copayment for specialist services. The total amount you are being asked to 
pay is $80 ($40 x 2 visits = $80). Specialist services fall within the physician/practitioner services/specialist 
visit 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 specialist services provided by a 
participating provider on March 17, 2020 to May 5, 2020.  
 
We note your complaint about being told that these copayments would be waived. Your complaint is a 
grievance that must be answered by the health plan. Medicare does not permit us to make a decision about 
these types of complaints.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a home ventilator and humidifier (E0466 and E0562). 
 
You asked the Plan to pre-approve the home ventilator and humidifier. You say that you would like 
reconsideration based on the records submitted. The Plan denied your request. The Plan says these supplies are 
not medically necessary. 
 
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 pre-approve the home ventilator and humidifier. Our 
reviewer says that the requested items/services are not considered medically reasonable and necessary in this 
case. Our physician reviewer found There is no documentation of CO2 retention while in a stable state.  BiPAP 
has not been tried. 
 
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 home ventilator and humidifier have not been met. Therefore, we decided 
that the Plan does not have to pre-approve a home ventilator and humidifier (E0466 and E0562).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for physician's services provided on June 17, 2020. 
 
You asked the Plan to pay for the physician's services. 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 
physician?s services. 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 physician's services provided on June 17, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit provided by an opted-out physician on May 7, 
2020. 
 
You asked the Plan to pay for office visit. You say that due to the serious nature of your condition, you felt that 
it was critical that you seek a second opinion and were referred to this provider by your treating cardiac 
surgeon. The Plan denied your request. The Plan says the denial of payment for this service is correct, because 
this provider has opted out of Medicare and is not payable. 
 
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 
an office visit provided by an opted-out physician on May 7, 2020.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a lampoon procedure, heart valve implantation (33999, 
0483T). 
 
You asked the Plan to pre-approve a lampoon procedure. You say that the services are necessary. The Plan 
denied your request. The Plan says medical necessity has not been established. Therefore, coverage criteria has 
not been met. 
 
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 pre-approve a lampoon procedure. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found based on the records, you have a combination of symptomatic severe mitral valve 
stenosis and moderate regurgitation. In this circumstance standard treatment is surgical mitral valve 
replacement. The documents do not support that surgical mitral valve replacement is contraindicated or of 
prohibitively high risk. Also, percutaneous mitral valve replacement in this setting is experimental and not 
adequately studied in this enrollee population. Coverage criteria are therefore not met. 
 
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 lampoon procedure have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a lampoon procedure, heart valve implantation (33999, 0483T).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for medical nutrition therapy (97802) provided on March 25, 
2020. 
 
You asked the Plan to pay for medical nutrition therapy. You say that this was medically necessary. The Plan 
denied your request. The Plan says this is not covered for the enrollee's condition. 
 
The Plan must follow Medicare rules. Medicare rules say that medical nutrition therapy is covered for certain 
beneficiaries who have diabetes or a renal disease. 
 
We looked at the file and Medicare rules. The record does not show that the enrollee has diabetes or a renal 
disease. Based on this information, we decided that Medicare rules for coverage of medical nutrition therapy 
have not been met. Therefore, we decided that the Plan does not have to pay for medical nutrition therapy 
(97802) provided on March 25, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve compression stockings identified with code A6549. 
 
You asked the Plan to pre-approve the compression stockings. You say that you require the stockings to 
prevent complications with lymphedema. The Plan denied your request. The Plan says the stockings are non-
reusable supply items therefore are not covered. 
 
The Plan must follow Medicare rules. The rules say that compression stockings described by code A6549 are 
noncovered because they do not meet the statutory definition of a surgical dressing.  
 
Although this item may be appropriate, it does not fall into a covered benefit category and cannot be paid for 
by Medicare or the Plan. Therefore, we decided that the Plan does not have to pre-approve compression 
stockings identified with code A6549.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the transportation of a portable x-ray (R0070) provided on 
May 18, 2020. 
 
You asked the Plan to pay for the transportation of the portable x-ray. You say that you would like 
reconsideration because the mobile setting was medically necessary. The Plan denied your request. The Plan 
says Medicare rule for payment of this claim has not been met as CPT code R0070 has a professional/technical 
component indicator of 3. 
 
The Plan must follow Medicare rules. Medicare rules say that if the patient is in a Part A SNF stay, the 
transportation and set up costs are subject to consolidated billing and not separately billable to Medicare Part B. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the transportation of the portable x-ray have not been met. Specifically, the record shows that this 
claim was billed with POS code 31, indicating that the member was in a Part A SNF stay. In this case, the 
transportation and set up costs are subject to consolidated billing and not separately billable to Medicare Part B. 
Therefore, we decided that the Plan does not have to pay for the transportation of a portable x-ray (R0070) 
provided on May 18, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the unspecified preventive procedure (D1999) on May 20, 
2020. 
 
You asked the Plan to pay for the unspecified preventive procedure (D1999). You say that you were not 
informed that these procedures were not covered. You say that you should be provided full coverage. The Plan 
denied your request. The Plan says the service is not a covered benefit. 
 
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 for the 
unspecified preventive procedure (D1999) on May 20, 2020.  
 
Your complaint about the doctors acting in a professional and ethical matter instead of maximizing profit 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: ER
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the emergency department visit (99285) 
provided on May 28, 2020. 
 
You asked the Plan to waive the copayment. You say that you are requesting a reconsideration of the Plan's 
denial for payment. The Plan denied your request. The Plan says the copayment was 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 $120 
copayment for each in-network and out-of-network Medicare-covered emergency room visit.  
 
You have been asked to pay a $120 copayment for the emergency department visit provided. 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 emergency department visit (99285) provided on May 28, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the routine eyewear rendered on May 23, 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 the services are not covered from a non-participating provider. 
 
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 up to $300 for routine eyewear from a network optical provider per calendar year. 
 
We looked at the file and the Plan's rules. The file shows that you received routine eyewear from a provider 
that was not a network optical provider. Based on this information, we decided that the Plan's rules for 
coverage of these services have not been met. Therefore, we decided that the Plan does not have to pay for the 
routine eyewear rendered on May 23, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for subsequent nursing facility care provided on November 8, 2019. 
 
You asked the Plan to pay for the subsequent nursing facility care. The Plan denied your request. The Plan says 
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 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 subsequent nursing facility care provided on November 8, 2019.