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

 
We decided that the Plan does not have to pay for the acupuncture treatment (97810, 97811) and the infrared 
therapy (97026) provided on December 1, 2021. 
 
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 the services are not payable as they were 
rendered by a non-covered provider type. Additionally, the services in this case were not provided on the basis 
of a covered diagnosis. 
 The Plan must follow Medicare rules. The rules say that acupuncture services are not covered by Medicare. 
However, for services provided on or after January 21, 2020, Medicare offers limited coverage for acupuncture 
treatments for CLBP meeting certain requirements, up to 12 sessions per 90-day period, and no more than 20 
sessions per year.  
 
We looked at the case file and Medicare rules. Based on this information, we decided that the rules for 
coverage of the acupuncture services provided have not been met. Specifically, the acupuncture treatment in 
this case was not provided under the supervision of a physician, physicians assistant, nurse practitioner or 
clinical nurse specialist. Additionally, these services were not provided on the basis of a covered diagnosis. 
Therefore, we decided that the Plan does not have to pay for the acupuncture treatment (97810, 97811) and the 
infrared therapy (97026) provided on December 1, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services provided on October 9, 2021. 
 
You asked the Plan to pay for the lab services. You say that you would like this claim reprocessed and 
approved for payment. The Plan denied your request. The Plan says you billed with an incorrect place of 
service on the claim. 
 
The Plan must follow Medicare rules. Medicare rules say that, for 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 lab 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 lab services provided on October 9, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the Covid-19 testing you received outside of the United 
States on March 21, 2022, and March 25, 2022. 
 
You asked the Plan to pay for the testing. The Plan denied your request. The Plan says this is not a covered 
benefit. 
 
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 $0 
copayment for worldwide coverage for emergency services outside of the United States.  
 
Review of the file shows that you were provided Covid-19 testing on March 21, 2022, and March 25, 2022. 
The Plan only covered emergency care provided outside of the United States. The Covid-19 testing was not 
urgent or emergent. 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 pay for the Covid-19 testing you received outside of the 
United States on March 21, 2022, and March 25, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the additional moderate sedation time provided on date of 
service May 13, 2022, billed with code 99153. 
 
You asked the Plan to pay for procedure code 99153. The Plan denied your request. The Plan says code 99153 
is not payable in the facility setting. 
 
Medicare rules say that the OPPS recognizes that CPT code 99153 is a PE only code and that PE are not 
payable to the physician for services provided in the facility setting.  
 
We find that payment for CPT code 99153 is not supported. Specifically, there is no separate payment to the physician for CPT code 99153 when performed in the facility setting. Therefore, we decided that the Plan does 
not have to pay for the additional moderate sedation time provided on date of service May 13, 2022, billed with 
code 99153.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 82435, 84132, and 84295 billed for date of 
service December 1, 2021. 
 You asked the Plan to pay for procedure codes 82435, 84132, and 84295. You say that you disagree with the 
denial. The Plan denied your request. The Plan says payment for codes 82435, 84132, and 84295 is bundled 
into payment for code 80051. 
 
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 codes 
82435, 84132, and 84295 are column II codes to column I code 80051. 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 codes 82435, 84132, and 84295 
billed for date of service December 1, 2021.
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 medical record summary to 
support the use of the pneumatic compression device for treatment of post-surgical edema, inflammation and 
venous insufficiency. 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 acupuncture treatment (97810, 97811) provided on 
December 15, 2021. 
 
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 the services are not payable as they were 
rendered by a non-covered provider type. Additionally, the services in this case were not provided on the basis 
of a covered diagnosis.  
  
 
 
The Plan must follow Medicare rules. The rules say that acupuncture services are not covered by Medicare. 
However, for services provided on or after January 21, 2020, Medicare offers limited coverage for acupuncture 
treatments for CLBP meeting certain requirements, up to 12 sessions per 90-day period, and no more than 20 
sessions per year.  
 
We looked at the case file and Medicare rules. Based on this information, we decided that the rules for 
coverage of the acupuncture services provided have not been met. Specifically, the acupuncture treatment in 
this case was not provided under the appropriate level of supervision of a physician, physician assistant, or 
nurse practitioner/clinical nurse specialist. Additionally, these services were not provided on the basis of a 
covered diagnosis. Therefore, we decided that the Plan does not have to pay for the acupuncture treatment 
(97810, 97811) provided on December 15, 2021.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home health care services provided on July 24, 2021. 
 
You asked the Plan to pay for the home health care services. You say that you would like this claim to be 
reprocessed for payment. The Plan denied your request. The Plan says the non-contracted provider did not 
submit the RAP claim for services for date of service July 24, 2021, until October 7, 2021. The Plan also says 
no exception request was submitted to the Health Plan to waive the 5-day requirement for filing the RAP claim 
due to a circumstance beyond the provider's control. 
 
The Plan must follow Medicare rules. Medicare rules say that all HHAs must submit a RAP within 5 calendar 
days after the start of care date for initial 30-day periods and within 5 calendar days after the from date for 
each subsequent 30-day period of care. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the home health care services have not been met. Specifically, the record indicates the RAP was 
not submitted within 5 days from the start of care date. Therefore, we decided that the Plan does not have to 
pay for the home health care services provided on July 24, 2021.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the physical therapy services rendered on December 7, 2021. 
 
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says the services were not billed correctly. 
 
The Plan must follow Medicare rules. Medicare rules say that therapy codes must be billed with the GP, GO, or 
GN modifier. 
 
We looked at the file and Medicare rules. The file shows that procedure code 97164 was not billed with the 
required GP, GO, or GN modifier. 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 pay for the physical 
therapy services rendered on December 7, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for genetic testing (0037U) billed for date of service January 13, 
2022. 
 
You asked the Plan to pay for genetic testing. You say that the service at issue was billed correctly. The Plan 
denied your request. The Plan says the service was billed with the incorrect DOS. 
 
The Plan must follow Medicare rules. Medicare rules say that the DOS of the test/service must be the date the 
specimen was collected. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of genetic testing have not been met. Specifically, the medical records do not support that the 
specimen was collected on the reported DOS. The records do not support an exception to the rule. Therefore, 
we decided that the Plan does not have to pay for genetic testing (0037U) billed for date of service January 13, 
2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for COVID-19 testing (U0004) billed for date of service January 
28, 2021. 
 
You asked the Plan to pay for COVID-19 testing. You say that the service at issue was billed correctly. The 
Plan denied your request. The Plan says rules for payment have not been met. 
 
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 U0004 is "2019-ncov coronavirus, sars-cov-2/2019-ncov 
(covid-19), any technique, multiple types or subtypes (includes all targets), non-cdc, making use of high 
throughput technologies as described by cms-2020-01-r." 
 
 
  We find that CPT code U0004 is not supported in the medical record. Specifically, the available records state 
that the specimen was found to be out of stability and the testing was not completed. Based on this information, 
we decided that Medicare rules for coverage of COVID-19 testing have not been met. Therefore, we decided 
that the Plan does not have to pay for COVID-19 testing (U0004) billed for date of service January 28, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve compression stockings identified with code A6533. 
 
You asked the Plan to pre-approve the compression stockings. You say that you are requesting a 
reconsideration of the Plan's denial. The Plan denied your request. The Plan says these items are not a covered 
benefit under your contractual policy or by Medicare. 
 
The Plan must follow Medicare rules. The rules say that compression stockings described by code A6533 are 
noncovered because they do not meet the statutory definition of a surgical dressing.  
 
 
 Although these items may be appropriate, they do 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 A6533.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for Contour Next diabetic test strips provided on February 5, 
2022. 
 
You asked the Plan to pay for Contour Next diabetic test strips. You say that you thought the items at issue 
would be covered. The Plan denied your request. The Plan says rules for payment have not been met. 
 
The Plan must follow Medicare rules. Medicare rules say that MA Plans may specify brands and manufacturers 
as preferred and charge lower cost-sharing for the preferred brands or may limit DME to only those preferred 
brands and manufacturers. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of Contour Next diabetic test strips have not been met. Specifically, the requested item is a non-
preferred brand. The case record does not contain medical documentation to support the medical necessity of 
the requested item. Therefore, we decided that the Plan does not have to pay for Contour Next diabetic test 
strips provided on February 5, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code S9328 billed for date of service June 18, 
2022, to July 15, 2022. 
 
You asked the Plan to pay for procedure code S9328. You say that the services at issue were billed correctly. 
The Plan denied your request. The Plan says the billed code is invalid for Medicare purposes. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate procedure code. 
 
We find that procedure code S9328 has a Status Indicator of I on the Physician Fee Schedule. This means that 
procedure code S9328 is not valid for Medicare purposes. Based on this information, we decided that Medicare rules for coverage of procedure code S9328 have not been met. Therefore, we decided that the Plan does not 
have to pay for procedure code S9328 billed for date of service June 18, 2022, to July 15, 2022.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home visit (99348) provided on May 3, 2022, by an out-
of-network (OON) provider. 
 
You asked the Plan to pay for the home visit. You say that medically necessary emergency wound care was 
provided in the absence of a contracted/available wound care professional. You also say that the physician 
rendered this service in good will, and the treatment performed should be reimbursed. The Plan denied your 
request. The Plan says the rendering provider contract with the Plan became effective on May 27, 2022, after 
this claim was billed, and there was no prior authorization on file. 
 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 
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 home visit (99348) provided on May 3, 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 anesthesia services (code 01936) provided on  
November 8, 2021. 
 
You asked the Plan to pay for anesthesia services. You say that this claim is not a duplicate and is a separate 
charge from any other services performed on this date of service. The Plan denied your request. The Plan says 
this claim is a duplicate of a previously paid claim and was correctly denied. 
 
The Plan must follow Medicare rules. The rules say that claims or claim lines that have been determined to be 
exact duplicates of another claim or claim line are denied. However, such denials may be appealed. 
 
We looked at the file and Medicare rules. The file includes evidence that the services at issue were reimbursed 
by the Plan on December 6, 2021. Comparison of the two claims shows these are exact duplicates. There is no 
evidence presented to support that the billed services were provided twice on the same date. Based on this 
information, we decided that the Medicare rules for anesthesia services have not been met. Therefore, we 
decided that the Plan does not have to pay for anesthesia services (code 01936) provided on November 8, 2021.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an ambulance ride provided on February 
29, 2020. 
 
You asked the Plan to waive the copayment for an ambulance ride. You say that this was an actual emergency, 
and so the copayment should be waived. The Plan denied your request. The Plan says this cost sharing was 
charged 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 $325 
copayment for ambulance services. 
 
You have been asked to pay a $325 copayment for an ambulance ride. This item/service falls 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. You have been asked to pay a $321.60 copayment, rather than the full copayment of $325 for 
ambulance services. Therefore, we decided that the Plan does not have to waive the copayment for an 
ambulance ride provided on February 29, 2020.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the self-administered drugs provided on July 6, 2022. 
 
You asked the Plan to pay for the self-administered drugs. You say that you were given two Tylenol tablets 
while you were in the hospital. The Plan denied your request. The Plan says self-administered drugs are not 
covered under Part B of Original Medicare. 
 
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-
administered drugs. The self-administered drugs requested here are not among the types which are covered by 
Medicare Part B. Therefore, we decided that the Plan does not have to pay for the self-administered drugs 
provided on July 6, 2022.  
 
Benefits for the self-administered drugs 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: Hospice
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the psychotherapy service (90832) provided on November 1, 
2021. 
 
You asked the Plan to pay for the psychotherapy service. You say that the service was medically necessary. 
The Plan denied your request. The Plan says the enrollees claim would be covered under Original Medicare as 
it is responsible for coverage of Part B benefits starting on the date of election until the last day of the month in 
which hospice is revoked. The Plan also says it is the providers responsibility to verify the enrollees coverage 
before rendering services and to know proper billing procedures for a Medicare Advantage member on hospice.  
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 dates of service at issue in this appeal. Therefore, 
we decided that the Plan does not have to pay for the psychotherapy service (90832) provided on November 1, 
2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a transthoracic echocardiogram. 
 
You asked the Plan to pre-approve the services. You say that this needs to be done again to evaluate the 
enrollee's condition. The Plan denied your request. The Plan says this does not have to be done for three to five 
years based on guidelines. 
 
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 services. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found that the the clinical documentation does not support that a repeat transthoracic echocardiogram is 
medically reasonable at this time (7 months after the last study), as the most recent symptoms and examination 
were unremarkable. A repeat echocardiogram yearly would be considered medically reasonable and necessary 
for the enrollee, sooner if indicated by symptoms or a change in the physical examination. There is no 
doucmentation to support evidence of new thromboembolic event, aneurysm, aortic dissection, new onset 
congestive heart failure, or new syncope. 
 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 services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a transthoracic echocardiogram.