Persius/hicric huggingface dataset:
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an electrocardiography (ECG) (93000) 
provided on February 10, 2022. 
 
You asked the Plan to waive the copayment for the ECG. You say that the services should be covered as you 
disagree with the charges. The Plan denied your request. The Plan says the cost-sharing applied correctly based 
on the services 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 $30 
copayment for Outpatient Diagnostic Tests and Therapeutic Services and Supplies.  
 
 
  You have been asked to pay a $12.65 copayment for the ECG, which is less than the standard $30. ECGs fall 
within the Outpatient Diagnostic Tests and Therapeutic Services and Supplies 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 an electrocardiography (ECG) (93000) provided on February 10, 
2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the domiciliary visit provided on January 14, 2022, by an 
out-of-network (OON) provider. 
 
You asked the Plan to pay for the domiciliary visit. You say that the provider relies on the hospital staff to 
verify eligibility and to obtain the proper authorization from the enrollee's insurance company. The Plan denied 
your request. The Plan says no prior authorization was 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 domiciliary visit in this appeal. The Plan did not pre-approve the 
domiciliary visit. We found no exception that would require the Plan to pay for the domiciliary visit. The 
records provided for review do not show that the domiciliary visit was urgent or emergent. Therefore, we 
decided that the Plan does not have to pay for the domiciliary visit provided on January 14, 2022, by an out-of-
network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for mechanical traction therapy (97012), electric stimulation 
therapy (97014), ultrasound therapy (97035), and the massage therapy (97124) provided from January 13, 
2020, through December 31, 2020. 
 
You asked the Plan to pay for these services. You say that you are requesting a reconsideration of the Plan's 
denial for payment. The Plan denied your request. The Plan says these services are not a covered benefit under 
your contractual policy or by Medicare. 
 
The Plan must follow Medicare rules. The rules say that the only chiropractic service Medicare covers is 
manual manipulation of the spine to correct a subluxation.  
 
The records show that the services at issue are not manual manipulation of the spine. Therefore, we decided 
that the Plan does not have to pay for mechanical traction therapy (97012), electric stimulation therapy 
(97014), ultrasound therapy (97035), and the massage therapy (97124) provided from January 13, 2020, 
through December 31, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve compression stockings identified with code A6530 and 
foot inserts (L3010). 
 
 You asked the Plan to pre-approve compression stockings and foot inserts. You say that you do not agree with 
the denial and are requesting reconsideration of the requested items. The Plan denied your request. The Plan 
says the requested gradient compression hose is only covered by Medicare when used for the purpose of being 
a secondary bandage for an open leg wound or to reduce hypertrophic scarring and joint contractures following 
burn injury. The Plan also says foot orthotics are not covered for a beneficiary who does not have diabetes, a 
foot brace, or a prosthesis. 
 
The Plan must follow Medicare rules. The rules say that compression stockings described by code A6530 are 
non-covered because they do not meet the statutory definition of a surgical dressing. Medicare rules also 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.   
 
Although compression stockings may be appropriate, it does not fall into a covered benefit category and cannot 
be paid for by Medicare or the Plan. Records show that the enrollee does not suffer from diabetic foot disease 
and does not wear a leg brace. Although orthotics may be appropriate for the enrollee, neither Medicare nor the 
Plan provides coverage of orthotics for the enrollee's condition. Therefore, we decided that the Plan does not 
have to pre-approve compression stockings identified with code A6530 and foot inserts (L3010).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the hospital outpatient visit (G0463) and debridement of 
subcutaneous tissue (11042) provided on February 15, 2022, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for the hospital outpatient visit and debridement. You say that the services were 
medically necessary. The Plan denied your request. The Plan says the services were provided out-of-network 
and were not approved in advance. 
 
 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 hospital outpatient visit (G0463) and 
debridement of subcutaneous tissue (11042) provided on February 15, 2022, by an out-of-network (OON) 
provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit (99214) provided on March 17, 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 (99214) provided on March 17, 
2022 by an out-of-network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for a wearable, external defibrillator provided 
on September 23, 2021. 
 
You asked the Plan to waive the coinsurance for a wearable, external defibrillator. You say that your 
cardiologist instructed you to remove the vest on October 4, 2021. You also say you returned the vest to the 
provider on October 5, 2021, and your last payment should have been for 11 days not the full month. The Plan 
denied your request. The Plan says you were 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 20 
percent coinsurance for each Medicare-covered item for durable medical equipment (DME) and related 
supplies.  
 
You have been asked to pay $586.29 in coinsurance, which is 20 percent of the allowed amount for a wearable, 
external defibrillator ($2,931.45 allowed amount x 20% coinsurance = $586.29). A wearable, external 
defibrillator falls within the durable medical equipment (DME) and related supplies 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 coinsurance for a wearable, external defibrillator provided on September 
23, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the outpatient office visit (99213) provided January 11, 2022. 
 
You asked the Plan to pay for the office visit. You say that the doctor's office says their bill is subject to a 
deductible and now you owe them $81.37. You are requesting a review as on your coverage says that you only 
have to pay $10.00 and says nothing about a deductible. The Plan denied your request. The Plan says this claim 
was processed with the correct cost share per the Evidence of Coverage. 
 
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 $500 deductible which applies to Physician/Practitioner Services, 
Including Doctor's Office Visits.  
 
The item or service you asked the Plan to pay for falls within the benefit category Physician/Practitioner 
Services, Including Doctor's Office Visits. Until you have paid the deductible amount, you must pay the full 
cost for most of your covered services. Once you have paid your deductible, the Plan will begin to pay their 
share of the costs for covered medical services and you will pay your share (your copayment or coinsurance 
amount) for the rest of the plan year. The Plan has followed Medicare rules by clearly disclosing in the contract 
that there is $500 deductible which applies to Physician/Practitioner Services, Including Doctor's Office Visits. 
This cost sharing is a contractual obligation that had not been met at the time the office visit was received on 
January 11, 2022. Therefore, we decided that the Plan does not have to pay for the outpatient office visit 
(99213) provided January 11, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for laboratory services provided to the enrollee on May 17, 
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 if a laboratory assays two or more genes in a patient in parallel, then those two or more genes 
will be considered part of the same panel. 
 
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 the various denied CPT codes are not supported in the medical record. Specifically, the testing at 
issue in this case should be reported with CPT 81479. 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 May 17, 2021.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a second computed tomography (CT) of the head or brain 
(70450) provided on January 7, 2022. 
 
You asked the Plan to pay for the second CT of the head or brain. The Plan denied your request. The Plan says 
the documentation does not support the CT of the head or brain which was billed twice. 
 The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate Current Procedural Terminology (CPT) code. 
 
In this case, the CPT Code Manual definition of code 70450 is Computed tomography, head or brain; without 
contrast material. 
 
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 second CT of the head or brain. Our reviewer says that 
the additional CT of the head or brain is not supported in the medical records Our reviewer found the records 
show a solitary CT of the brain was done on January 7, 2022. Our reviewer also found that no second exam on 
same date is documented. 
 
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 second CT of the head or brain have not been met. Therefore, we decided 
that the Plan does not have to pay for a second computed tomography (CT) of the head or brain (70450) 
provided on January 7, 2022.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 76942 billed for date of service December 
30, 2021. 
 You asked the Plan to pay for procedure code 76942. You say that you would like the Plan to reconsider their 
denial of payment. The Plan denied your request. The Plan says payment for code 76942 is bundled into 
payment for code 20610. 
 
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 76942 
is a column II code to column I code 20610. 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 76942 billed for date of service December 30, 
2021.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care after July 21, 2022. 
 
You asked the Plan to pre-approve SNF care after July 21, 2022. You say that the continued admission to a 
SNF is medically necessary. The Plan denied your request. The Plan says the continued admission to a SNF is 
not medically necessary. 
 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 after July 21, 2022. Our 
reviewer says that you do not meet the Medicare criteria for continued SNF care. Our physician reviewer found 
you do not have documented skilled nursing or therapy needs. Your care needs, as a practical matter, can be 
provided at a lower level of care. 
 
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 after July 21, 2022, have not been met. Therefore, we decided that the 
Plan does not have to pre-approve skilled nursing facility (SNF) care after July 21, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the specimen validity testing provided on March 18, 2021. 
 
You asked the Plan to pay for the testing. The Plan denied your request. The Plan says this is not payable. 
 
The Plan must follow Medicare rules. Medicare rules say that providers performing validity testing on urine 
specimens utilized for drug testing shall not separately bill the validity testing.  
 
We looked at the file and Medicare rules. The requested validity testing is not separately payable. Based on this 
information, we decided that Medicare rules for coverage of the testing have not been met. Therefore, we 
decided that the Plan does not have to pay for the specimen validity testing provided on March 18, 2021.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a duplex scan (93971) performed January 23, 2022. 
 
You asked the Plan to pay for the duplex scan. You say that this service was medically necessary. The Plan 
denied your request. The Plan says the claim is a duplicate. 
 
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 93971 is not supported in the medical record. Specifically, this code was previously 
paid for the same date of service. Records do not support an additional unit. Based on this information, we 
decided that Medicare rules for coverage of the duplex scan have not been met. Therefore, we decided that the 
Plan does not have to pay for a duplex scan (93971) performed January 23, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a gastric peroral endoscopic myotomy (G-POEM) for 
the enrollee. 
 
You asked the Plan to pre-approve these services. You say that these services are medically necessary. The 
Plan denied your request. The Plan says that the clinical value and effectiveness of G-POEM in the setting of 
gastroparesis and GERD has not been demonstrated in the 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 these services. Our reviewer says that 
the requested services are not considered medically reasonable and necessary in this case. G-POEM is still a 
novel technique that while promising is not standard-of-care. Further, no objective data was presented with 
records that demonstrate improvement in gastric emptying rates pre versus post-Botox, nor does available 
documentation support that his symptoms are medically-refractory. Of further concern unique to this case, the 
enrollee is high risk for endoscopic sedation given his multiple comorbidities. G-POEM may not at this time 
represent his best or safest option. Our physician reviewer found that the enrollee's condition does not meet 
criteria for coverage of these services.  
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of these services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a gastric peroral endoscopic myotomy (G-POEM) for the enrollee.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission 
and services for the enrollee. 
 
You asked the Plan to pre-approve IRF care. You say that these services are medically necessary. The Plan 
denied your request. The Plan says that the enrollee does not require intensive therapy at least three hours per 
day, five days per week. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 
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 IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. The 
enrollee is medically stable and does not need physical medicine and rehabilitation physician supervision 3 times per week (at a minimum) for the ongoing management of any active or acute exacerbations of chronic 
medical conditions. There are no acute rehab nursing needs identified or documented. An uncomplicated hip 
fracture patient does not require an admission to IRF. The enrollee does not need intensive therapies consisting 
of at least 3 hours of therapy per day at least 5 days per week with multidisciplinary approach in an IRF. While 
the enrollee may benefit from continued physical and occupational therapy, the enrollee's rehab needs can be 
safely provided in a lower intensity and alternate setting. Our physician reviewer found that the enrollee's 
condition does not meet Medicare criteria for IRF care. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services for the enrollee.