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

 
We decided that the Plan has to pay for the emergency ambulance transportation (A0427) and ground mileage 
(A0425) provided on November 24, 2021. 
 
You asked the Plan to pay for the emergency ambulance transportation and ground mileage. You say that you 
believe these charges should be covered. The Plan denied your request. The Plan says that the information 
provided does not support medical necessity for ambulance transport. 
 
Medicare pays for ambulance services only when an emergency exists or when other means of transport would 
endanger the patients health. The Plan follows the same rules.  
 
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 emergency ambulance transportation and ground mileage. Our reviewer says that the elements of 
the coverage criteria are satisfied. Our physician reviewer found the record indicates that the enrollee had a 
complaint of nausea and weakness for two weeks and was found to have a first-degree atrioventricular block on 
electrocardiogram. Our reviewer found that the enrollee was transported form a clinic to the hospital for a 
higher level of care. A prudent layperson would believe that without immediate medical attention there would 
be serious jeopardy to his or her health in this situation. 
 
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 emergency ambulance transportation and ground mileage have been met. 
Therefore, we decided that the Plan has to pay for the emergency ambulance transportation (A0427) and 
ground mileage (A0425) provided on November 24, 2021.  
 
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again 
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake 
and/or send us the new information. This does not happen often. If we decide to open the case again, we will 
send you a letter.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the office visit provided on April 15, 2021. 
 
You asked the Plan to pay for the office visit. You say that this visit is not related to the care from January 19, 
2021. You say that the claim has not been filed twice and should be reviewed. The Plan denied your request. 
The Plan says this service is within the global period of another procedure code. 
 
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 99214 is office or other outpatient visit for the evaluation 
and management of an established patient, which requires a medically appropriate history and/or examination 
and moderate level of medical decision making. When using time for code selection, 30-39 minutes of total 
time is spent on the date of the encounter. 
 
We find that CPT code 99214 is not supported in the medical record. Specifically, CPT code 66984 has a 
global period of 90 days. CPT code 99214 was billed within these 90 days and there is no indication that these 
services are unrelated. Based on this information, we decided that Medicare rules for coverage of the office 
visit have not been met. Therefore, we decided that the Plan does not have to pay for the office visit provided 
on April 15, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the Guardant 360 testing (81479) provided on August 9, 
2021. 
 
You asked the Plan to pay for the Guardant360 testing. You say that you would like reconsideration based on 
the records submitted. The Plan denied your request. The Plan says this claim was not submitted with the 
appropriate POS code. 
 
The Plan must follow Medicare rules. Medicare rules say that lab services, the POS code must reflect the 
location in which the sample was taken. POS code 81 is used to describe samples taken by the laboratory directly. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the Guardant360 testing have not been met. Specifically, this claim was billed with the laboratory 
POS code. The records do not support that the sample was taken in a laboratory setting. Therefore, we decided 
that the Plan does not have to pay for the Guardant 360 testing (81479) provided on August 9, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for laboratory services provided to the enrollee on August 2, 
2021. 
 
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 the denied code remains not supported. 
 
The Plan must follow Medicare rules. Medicare rules say that lab services, the POS code must reflect the 
location in which the sample was taken. POS code 81 is used to describe samples taken by the laboratory 
directly. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the services have not been met. Specifically, this claim was billed with the laboratory POS code. 
The records do not support that the sample was taken in a laboratory setting. Therefore, we decided that the 
Plan does not have to pay for laboratory services provided to the enrollee on August 2, 2021.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the arthrocentesis (20610) provided on October 14, 2021. 
 
You asked the Plan to pay for the arthrocentesis (20610). You say that the claim denied stating it is post-
operative to a surgery which is incorrect. You say that attached information should be reviewed and the claim 
should be adjusted to pay according to the member's plan. The Plan denied your request. The Plan says this 
service is within the global period of another procedure code. 
 
The Plan must follow Medicare rules. The rules say that the Medicare approved amount for certain procedures 
includes payment for the services related to the surgery when furnished by the physician who performs the 
surgery. 
 
In this case, the CPT Code Manual definition of code 20610 is arthrocentesis, aspiration and/or injection, major 
joint or bursa (eg, shoulder, hip, knee, subacromial bursa); without ultrasound guidance. 
 
We find that CPT code 20610 is not supported in the medical record. Specifically, CPT code 29879 has a 
global period of 90 days. CPT code 20610 was billed within these 90 days and there is no indication that these 
services are unrelated. Based on this information, we decided that Medicare rules for coverage of the 
arthrocentesis (20610) have not been met. Therefore, we decided that the Plan does not have to pay for the 
arthrocentesis (20610) provided on October 14, 2021.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve admission to a skilled nursing facility (SNF). 
 
You asked the Plan to pre-approve SNF care. You say that SNF care is medically reasonable and necessary for 
the enrollee's condition. The Plan denied your request. The Plan says rules for SNF care have not been met. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors 
listed in the Medicare rules section 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 pre-approve SNF care. Our reviewer says that daily 
skilled services are not necessary. Our physician reviewer found the enrollee is a 74-year-old female with a 
past medical history of elevated blood pressure who presented to the acute hospital on April 6, 2022, with a left 
femur subtrochanteric fracture due to a fall. In this case, there is no documentation that the patient requires 
skilled nursing services, i.e., the specialized skill, knowledge and judgment of a skilled professional nurse are 
not required to safely and effectively provide medically necessary and reasonable treatment. Records do not 
document the need for intravenous medications, new tube feeding, or ostomy care or daily complex wound 
care. While this patient does require skilled therapy services, i.e., the specialized skill, knowledge and 
judgment of a qualified therapist are required to safely and effectively provide medically necessary and 
reasonable treatment, these services are not required on a daily basis. In conclusion, services in the home with 
home health care or in a long-term care facility on a part time basis appear appropriate in this case. 
 
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 care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve admission to a skilled nursing facility (SNF).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Minuteman interspinous device. 
 
You asked the Plan to pre-approve the requested services. You say that the enrollee failed conservative 
treatment. The Plan denied your request. The Plan says the clinical effectiveness has not been demonstrated in 
peer-reviewed literature. 
 
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 requested services. Our physician 
reviewer found that the minuteman interspinous device is experimental. More research is needed to show safety 
and efficacy. Therefore, the requested device is not considered medically reasonable or necessary. 
 
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 requested services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a Minuteman interspinous device.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an outpatient office visit provided on January 31, 2022, by an 
out-of-network (OON) provider. 
 
You asked the Plan to pay for the outpatient office visit. You say that you were unaware that the provider was 
an out-of-network provider. The Plan denied your request. The Plan says the rendering provider is an out-of-
network provider, and it was confirmed there was no referral from the enrollee's primary care physician. Also, 
the service rendered was not urgent, emergent, or pre-approved. 
 
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 had network providers 
available who could have provided 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 an outpatient office visit provided on January 31, 
2022, by an out-of-network (OON) provider.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an Intracept intraosseous nerve ablation procedure. 
 
You asked the Plan to pre-approve the requested services. You say that this procedure improves the quality of 
life of the enrollee. The Plan denied your request. The Plan says there is little evidence to suggest this is an 
appropriate procedure for the enrollee's back pain. 
 
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 requested services. Our physician 
reviewer found that the Intracept procedure is experimental. More research is needed to show safety and 
efficacy. Therefore, the requested service is not medically reasonable or necessary. 
 
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 requested services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve an Intracept intraosseous nerve ablation procedure.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a specialist office visit provided on 
December 30, 2021. 
 
You asked the Plan to waive the copayment for the specialist office visit. You say that the visit was preventive 
and should be covered. The Plan denied your request. The Plan says you have been charged the correct cost 
sharing 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). Your contract with the Plan clearly says that you must pay a $50 
copayment for each specialist visit.  
 
You have been asked to pay a $50 copayment for the specialist office visit. The specialist office 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 office visit provided on December 30, 2021.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for ambulance services provided on August 23, 
2021. 
 
You asked the Plan to waive the copayment for ambulance services. You say that this was denied because it 
was not filed as COVID-19. You also say that the provider needs you to pay the $250 copayment and you do 
not have it. The Plan denied your request. The Plan says you have been charged the correct cost sharing 
amount. The Plan also says that the claim was processed at the in-network rate. 
 
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 $250 
copayment for ground ambulance transportation.  
 The record shows this claim was approved, and you have a cost sharing amount. You have been asked to pay a 
$250 copayment for ambulance services. Ambulance services fall within the Ambulance Services 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 ambulance services provided on August 23, 
2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the deductible for anticoagulant management provided on 
September 17, 2021, and September 28, 2021. 
 
You asked the Plan to waive the deductible for anticoagulant management. You say that according to your 
records, you should have met your $600 deductible by end of May or June of 2021. The Plan denied your 
request. The Plan says you have been charged the correct cost sharing amount. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information. Your 
contract with the Plan says that there is $600 deductible which applies to in-network specialist services.  
 
The record shows your deductible had not been met at the time of service. As of September 15, 2021, an 
adjustment was made to a previously processed claim. This adjustment reduced the amount of your total 
deductible paid for the year. The anticoagulant management you asked the Plan to waive the deductible for 
falls within the Physician/Practitioner Services, Including Doctors Office Visits benefit category. The Plan has followed Medicare rules by clearly disclosing in the contract that there is $600 deductible which applies to in-
network specialist services. This cost sharing is a contractual obligation that had not been met at the time 
anticoagulant management was received on September 17, 2021, and September 28, 2021. Therefore, we 
decided that the Plan does not have to waive the deductible for anticoagulant management provided on 
September 17, 2021, and September 28, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for speech/hearing therapy (92507) provided on March 6, 2021, 
by an out-of-network (OON) provider. 
 
You asked the Plan to pay for speech/hearing therapy. You say that that another claim for the same procedure 
was partially paid. The Plan denied your request. The Plan says this provider is out-of-network with the Plan, 
and authorization was not obtained prior to the services being rendered. The Plan also says that the referring 
provider was out-of-network with the Plan, and the services rendered were not Plan directed care. The Plan also 
says that the appellant did not reference a date of services, which she alleges was previously paid so we cannot 
validate. 
 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 had network providers 
available who could have provided 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 speech/hearing therapy (92507) provided on 
March 6, 2021, 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 oxygen chamber therapy session provided on November 
11, 2021, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for the oxygen chamber therapy session. You say that the enrollee was seen out of 
medical necessity and would like the claim processed for payment. The Plan denied your request. The Plan 
says the rendering provider is an out-of-network provider and there was no referral from an in-network 
provider or an approved authorization. Also, the service rendered was 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 had network providers 
available who could have provided 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 oxygen chamber therapy session provided on 
November 11, 2021, by an out-of-network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Favorable

 
We decided that the Plan has to pay for the Continuous Glucose Monitor (K0553) provided on May 22, 2021. 
 
You asked the Plan to pay for the Continuous Glucose Monitor. You say that you would like reconsideration 
based on the records submitted. The Plan denied your request. The Plan says that this provider is involved in a 
telemarketing scheme. 
 
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and 
diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or 
payment. 
 
The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their 
decision to deny your request. Specifically, the Plan's denial indicates that there is no established relationship 
between the enrollee and a telehealth provider. The medical records and physician order provided to not 
indicate that the telehealth provider is involved in this case. The record includes a physician order and relevant 
medical records which indicate a relationship between the enrollee and requesting provider. The Plan has not 
forwarded any evidence to support misrepresented services. It is the burden of the Health Plan to substantiate 
their denial with evidence. In this case, the Plan's denial has not been substantiated so we must find in your 
favor Therefore, we decided that the Plan has to pay for the Continuous Glucose Monitor (K0553) provided on 
May 22, 2021.  
 
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again 
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake 
and/or send us the new information. This does not happen often. If we decide to open the case again, we will 
send you a letter.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the blood bank physician services (86077) provided on 
October 19, 2021. You asked the Plan to pay for the blood bank physician services. You say that you would like reconsideration 
based on the records submitted. The Plan denied your request. The Plan says CPT 86077-59 has an MUE value 
of 1 and the provider billed 2 units. 
 
The Plan must follow Medicare rules. Medicare rules say that claims submitted where the unit of service 
exceeds the MUE value cannot be paid when the MAI value is 2.  
 
In this case, the MUE for CPT code 86077 is 1. The MAI value for this code is 2. You billed 2 units of this 
code, exceeding the MUE. Based on this information, we decided that Medicare rules for coverage of the blood 
bank physician services have not been met. Therefore, we decided that the Plan does not have to pay for the 
blood bank physician services (86077) provided on October 19, 2021.