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

 
We decided that the Plan does not have to pay for ambulance transport services provided on January 8, 2022. 
 
You asked the Plan to pay for ambulance transport services. You say that the services at issue were a medical 
necessity for the enrollee. The Plan denied your request. The Plan says rules for payment have not been met 
because the enrollee was enrolled in hospice on the date of service. 
 
Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice 
services. Medicare hospice pays for claims related to the terminal illness. The rules say that the Plan may direct the provider to bill Medicare directly for these services.  
 
The enrollee was under the Medicare hospice benefit for the date of service at issue in this appeal. Therefore, 
we decided that the Plan does not have to pay for ambulance transport services provided on January 8, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a pneumatic compression device (E0675). 
 
You asked the Plan to pay for a pneumatic compression device. You say that the enrollee was treated for post-
surgical lymphedema. You disagree with this denial and believe these services were medically necessary. The 
Plan denied your request. The Plan says pneumatic compression device is not covered by Medicare to prevent 
deep vein thrombosis during and/or following surgery. 
 
The Plan follows Medicare rules. The rules state that a PCD that provides intermittent limb compression for the 
purpose of prevention of venous thromboembolism (E0676) is a preventive service. The rules also say that a 
PCD coded as E0675 to treat peripheral arterial disease is not eligible for reimbursement. 
 
We looked at the file and Medicare rules. Based on this information we decided that Medicare rules for 
coverage of the PCD have not been met. Specifically, this item is not a covered benefit of Medicare or the Plan. 
PCDs are not covered for preventions of venous thromboembolism nor for treatment of peripheral artery disease, regardless of how they are billed on the claim. Therefore, we decided that the Plan does not have to 
pay for a pneumatic compression device (E0675).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the tetanus vaccination and related charges you received on 
February 11, 2022. 
 
You asked the Plan to pay for the tetanus vaccination and related charges. You say that your doctor told you 
that this vaccination was good preventive medicine. The Plan denied your request. The Plan says this 
vaccination is not covered under your medical benefits. In the absence of injury or direct exposure to illness, 
Medicare does not pay for or provide the tetanus vaccination and related charges. The Plan follows the same 
rules. Records do not show that you have been injured or directly exposed to any illness related to the tetanus 
vaccination and related charges. Therefore, we decided that the Plan does not have to pay for the tetanus 
vaccination and related charges you received on February 11, 2022.  
 
Benefits for the tetanus vaccination may be available under Medicare Part D. Contact the Plan that administers 
Part D benefits for further information concerning any benefits and appeal rights.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit provided on January 28, 2022 by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for the office visit. You say that the services should be covered as you disagree with 
the denial. The Plan denied your request. The Plan says the services denied correctly as they were non-
emergent and prior authorization was not obtained. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
 
  The requested provider in this case is not a network provider with the Plan. The Plan 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 office visit provided on January 28, 2022 by an 
out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayments for podiatry services you received from 
March 25, 2022, to April 18, 2022. 
 
You asked the Plan to waive the copayments for the podiatry services. You say that these services should be 
considered post-surgery visits and should not have a separate copayment. The Plan denied your request. The 
Plan says you were charged these copayments correctly. 
 
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 podiatry services.  
 
You have been asked to pay a $20 copayment for each of the podiatry services. Records show that the services 
for which each copayment applied were not 'follow-up' office visits.  Rather, they were form partial removal of 
a metatarsal (date of service March 25, 2022) and debridement (each of the other dates of service).  Because 
these specific services are not just evaluation and management services but rather distinct procedures on their 
own, separate cost sharing can apply. 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 copayments for podiatry services 
you received from March 25, 2022, to April 18, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99233 billed for date of service November 
18, 2021. 
 You asked the Plan to pay for procedure code 99233. You say that you have provided records to show the 
medical necessity of this service. The Plan denied your request. The Plan says payment for code 99233 is 
bundled into payment for code 32555. 
 
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, we have confirmed that code 99233 
is a column II code to column I code 32555. This claim has not been billed with an appropriate modifier to 
bypass the edit. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we 
decided that the Plan does not have to pay for procedure code 99233 billed for date of service November 18, 
2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to issue reimbursement for the inpatient behavioral health services 
rendered by the out-of-network (OON) provider from September 13, 2021, through September 28, 2021. 
 
You asked the Plan to issue reimbursement 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 or a referral. 
 
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 issue reimbursement 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 had network providers available 
who could have provided 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 issue reimbursement for these services. Therefore, we 
decided that the Plan does not have to issue reimbursement for the inpatient behavioral health services rendered 
by the out-of-network (OON) provider from September 13, 2021, through September 28, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the wig you purchased on February 15, 2022. 
 
You asked the Plan to pay for the wig. You say that you have alopecia and must wear a wig. You said that wigs 
have been covered for you in the past. The Plan denied your request. The Plan says wigs are not covered for 
your condition. 
 
Medicare may pay for items which either meet the definition of DME or a prosthesis when these items are 
ordered by a physician. In this case, although the wig may be appropriate, it does not meet the definition of the 
above benefit categories. It is not considered DME because it does not directly treat a medical condition. It 
does not meet the Medicare definition of a prosthetic because it does not replace an internal body organ or 
attached tissue. As such, it is noncovered by Medicare. While the Plan does offer a supplemental benefit which 
would provide coverage for a wig, this benefit only covers wigs for members who experience hair loss due to treatment for cancer.  Your records show that you purchased this wig for alopecia, not for hair loss related to 
cancer treatment. As a result, there is no coverage for this wig, regardless of what may have been covered in 
the past. Therefore, we decided that the Plan does not have to pay for the wig you purchased on February 15, 
2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for surgical services (procedure code 43659) provided to the 
enrollee on November 30, 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 records 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 43659 is "unlisted laparoscopic procedure of the 
stomach." 
 
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 services. Our reviewer says that the services at issue in 
this case were not supported in the medical records. Our reviewer found that the operative report does not 
support the unlisted CPT code 43659. The operative report more supports CPT 43775 - laparoscopic vertical 
sleeve gastrectomy. A gastroplexy is not a standard medically necessary component of a laparoscopic vertical 
sleeve gastrectomy.  
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 services have not been met. Therefore, we decided that the Plan does not 
have to pay for surgical services (procedure code 43659) provided to the enrollee on November 30, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for laboratory services provided to the enrollee on February 16, 
2022. 
 
You asked the Plan to pay for the services. You say that this should be immediately paid for. The Plan denied 
your request. The Plan says the date of service for a clinical laboratory test or the technical component of a 
physician pathology service must be the date the specimen was collected. 
 
The Plan must follow Medicare rules. Medicare rules say that the date of service of the test/service must be the 
date the specimen was collected. 
 
The specimens were collected on both August 6, 2021 and January 14, 2022. A February 16, 2022 date of 
service is not appropriate in this case. 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 laboratory 
services provided to the enrollee on February 16, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99291 billed for date of service January 20, 
2022. 
 
You asked the Plan to pay for procedure code 99291. You say that the medical records support the billing of 
code 99291. The Plan denied your request. The Plan says this code is not supported by the medical record. 
 
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 99291 is evaluation and management of the critically ill 
or critically injured patient, first 30-74 minutes. This code is a timed code, meaning that the number of minutes 
providing critical care services must be documented in the medical record. There is no documentation in the 
medical record of how many minutes the provider spent with the patient providing this service.  Without this 
documentation of the number of minutes, code 99291 cannot be supported. Therefore, we decided that the Plan 
does not have to pay for procedure code 99291 billed for date of service January 20, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 64450 billed for date of service July 21, 
2021. 
 You asked the Plan to pay for procedure code 64450. You say that the medical records support payment of this 
code. The Plan denied your request. The Plan says payment for code 64450 is bundled into payment for code 
25605. 
 
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, we have confirmed that code 64450 
is a column II code to column I code 25605. This claim has not been billed with an appropriate modifier to 
bypass the edit. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we 
decided that the Plan does not have to pay for procedure code 64450 billed for date of service July 21, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for laboratory services provided on April 28, 2022, by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for laboratory services. You say that you would like to request reconsideration for 
payment. The Plan denied your request. The Plan says the provider is out-of-network and authorization is 
required prior to an out-of-network visit. 
 
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 laboratory services provided on April 28, 2022, by 
an out-of-network (OON) provider.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the computed tomography (CT) scan provided on March 8, 
2022, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for the CT scan. You say that this was an emergency and should be covered. The 
Plan denied your request. The Plan says unauthorized, non-plan care is not covered. 
 
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 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 computed tomography (CT) scan provided on 
March 8, 2022, by an out-of-network (OON) provider.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pay for skilled nursing facility (SNF) services provided to the 
enrollee from September 1, 2021, to September 30, 2021. 
 You asked the Plan to pay for SNF care. You say that this was medically necessary. The Plan denied your 
request. The Plan says there is no evidence that the enrollee received or required skilled level services during 
the appeal period in question. 
 
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 pay for SNF care. Our reviewer says that the 
requested SNF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found that the enrollee did not have documented skilled nursing needs. The enrollee did not 
have documented skilled therapy needs. Daily skilled services are not shown to have been required to establish 
a maintenance program or to prevent deterioration of the enrollees condition. 
 
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 pay for skilled nursing facility (SNF) services provided to the enrollee from September 1, 2021, to 
September 30, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for laboratory services provided on January 28, 2022, by an out-
of-network (OON) provider. 
 
You asked the Plan to pay for laboratory services. You say that the services provided were medically 
necessary. The Plan denied your request. The Plan says the provider is out-of-network and authorization is 
required prior to an out-of-network visit. 
 
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 laboratory services provided on January 28, 2022, 
by an out-of-network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an oral device/appliance provided on February 28, 2022, by 
an out-of-network (OON) provider. 
 
You asked the Plan to pay for an oral device/appliance. You say that you would like to request reconsideration 
of the denied claim. The Plan denied your request. The Plan says the provider is out-of-network, and it was 
determined these services can be received 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 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 oral device/appliance provided on February 28, 
2022, by an out-of-network (OON) provider.
Appeal type: Imaging
Decision: Favorable

 
We decided that the Plan has to pay for aortography and angiography (procedure codes 75625, 75710) provided 
to the enrollee on May 19, 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 that the codes cannot be verified. 
 
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 
the denied codes is: 
 
CPT 75625: 
 
Aortography, abdominal, by serialography, radiological supervision and interpretation 
 
CPT 75710: 
 
Angiography, extremity, unilateral, radiological supervision and interpretation 
 
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 services. Our reviewer says that the services at issue in 
this case were supported by the medical records. Our reviewer found that the enrollee underwent coronary 
artery catheterization - CPT 93454 - on 5/19/21. She also had selective catheterization of her aorta and left 
lower extremity during the same visit. CPT 75625 and CPT 75710 were billed as separate exams unrelated to 
the coronary procedure but denied as not substantiated. The report and attached documents support the need for 
a different procedure on the left leg arterial system differing from the coronary catheterization. Thus, in this 
case there is support for separate billing CPT 75625 and CPT 75710. 
 
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 services have been met. Therefore, we decided that the Plan has to pay for 
aortography and angiography (procedure codes 75625, 75710) provided to the enrollee on May 19, 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.