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

 
We decided that the Plan does not have to pay for the non-emergency wheelchair van transportation service 
provided on November 3, 2021. 
 
You asked the Plan to pay for the wheelchair van transport. You say that you needed transportation from the 
hospital to your home. The Plan denied your request. The Plan says that wheelchair van transport to your home 
is not covered. 
 
The Plan must follow Medicare rules. The rules say that Medicare does not pay for wheelchair van transport 
services.  
 
The services you have asked the Plan to pay for are wheelchair van transport services. Therefore, we decided that the Plan does not have to pay for the non-emergency wheelchair van transportation service provided on 
November 3, 2021.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the paramedic intercept service provided September 20, 
2021. 
 
You asked the Plan to pay for the paramedic intercept service. You say that you did not request, nor did you 
need the service. The Plan denied your request. The Plan says since you were not transported by this 
ambulance, the service is not covered under your plan. 
 
The rules say that Medicare pays for advanced life support (ALS), in accordance with state and local laws by 
an emergency medical technician (EMT) intermediate or EMT-Paramedic only in certain circumstances. Medicare allows ALS paramedic intercept services only when the services are furnished in a rural area as 
defined above. It is noted that the only State in which these criteria are met is New York. 
 
The paramedic intercept services at issue in this appeal were not furnished in an area that is considered rural 
according to the Medicare definition. Therefore, we decided that the Plan does not have to pay for the 
paramedic intercept service provided September 20, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a home health visit provided on September 25, 2021, by an 
out-of-network (OON) provider. 
 
You asked the Plan to pay for the home health visit. You say that it was medically necessary to treat the 
enrollee and the facility should have obtained the authorization prior to treatment. 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 a home health visit provided on September 25, 
2021, by an out-of-network (OON) provider.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve minimally invasive foot surgery to be provided by a 
non-Medicare enrolled physician and facility. 
 
You asked the Plan to pre-approve the requested foot surgery. You say that you feel that this should be covered 
because you wish to have minimally invasive surgery. You have been told from others that the Plan approved 
this facility because they do not offer this type of procedure from network providers. The Plan denied your 
request. The Plan says services from non-Medicare providers cannot be covered by the Plan. In addition, there 
is not sufficient evidence to support this minimally invasive surgical technique. 
 
The Plan must follow Medicare rules. The rules say that Medicare payment cannot be made to a provider that is 
not enrolled in the Medicare program. 
 
Review of the file and Medicare records indicates that the physician and surgical center at issue are not 
enrolled in the Medicare program. Therefore, we decided that the Plan does not have to pre-approve minimally 
invasive foot surgery to be provided by a non-Medicare enrolled physician and facility.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for screening digital breast tomosynthesis, bilateral and 
screening mammography, bilateral (2-view study of each breast), including computer-aided detection (CAD) 
provided on November 11, 2021. 
 
You asked the Plan to pay for screening digital breast tomosynthesis, bilateral and screening mammography, 
bilateral (2-view study of each breast), including computer-aided detection (CAD). You say that the services 
were medically necessary. The Plan denied your request. The Plan says the Plan was unable to obtain the 
explanation of benefits from the primary insurance carrier. The Plan must follow Medicare rules. The rules state that Medicare plans are considered secondary insurers 
when an enrollee has another type of insurance. This means that the Plan is not responsible for paying for 
services until the claim for those services has gone to the primary insurer. However, plans are still required to 
coordinate their benefits with the primary insurers. Plans can coordinate their benefits with the primary insurers 
in three ways. First, the Plan can send the bill directly to the primary insurer for payment. Second, the Plan can 
direct the provider to send the bill to the primary insurer. Third, the Plan can pay for the services and submit a 
bill for reimbursement to the primary insurer. 
 
The Plan has met its obligation with regards to coordination of benefits. Specifically, the Plan has tried to 
obtain the explanation of benefits from the primary insurance carrier. As the secondary insurer, the Plan cannot 
be held responsible for screening digital breast tomosynthesis, bilateral and screening mammography, bilateral 
(2-view study of each breast), including computer-aided detection (CAD) until the primary insurer has denied 
the claim for these services. Therefore, we decided that the Plan does not have to pay for screening digital 
breast tomosynthesis, bilateral and screening mammography, bilateral (2-view study of each breast), including 
computer-aided detection (CAD) provided on November 11, 2021.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home health services provided to the enrollee from May 
15, 2021 to June 10, 2021. 
 
You asked the Plan to pay for home health services. You say that you would like reconsideration based on the 
records submitted. The Plan denied your request. The Plan says this claim was not billed correctly. 
 The Plan must follow Medicare rules. The rules say that certain data elements on the RAP and the claim must 
be completed for home health care services to be covered. 
 
We looked at the claim submitted, the file and the Medicare rules. Based on this information, we decided that 
Medicare rules for completing the claim for home health services have not been met. Specifically, the claim 
does not have both the first visit and service location reported with the same date of service. Therefore, we 
decided that the Plan does not have to pay for the home health services provided to the enrollee from May 15, 
2021 to June 10, 2021.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve home health skilled nursing visits for venipuncture for 
lab testing. 
 
You asked the Plan to pre-approve the requested home health skilled nursing services. You say that your 
husband is immunocompromised, and you do not want to expose him to COVID-19 if you go to get this blood 
testing done in person. You feel that the home health services should be approved due to this issue. The Plan 
denied your request. The Plan says home health services are not covered if the sole purpose is for venipuncture 
for blood draws. 
 
The Plan must follow Medicare rules. Medicare rules say that home health services are not covered if the sole 
purpose is to obtain blood for lab testing. 
 
The record clearly indicates these services are requested solely for blood draws. Therefore, we decided that the 
Plan does not have to pre-approve home health skilled nursing visits for venipuncture for lab testing.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a group 2 heavy duty power wheelchair represented by 
code K0824, a cup holder, a side bag, and a bracket represented by code K0108. 
 
You asked the Plan to pre-approve codes K0824 and K0108. You say that you cannot walk more than a few 
feet before your feet give out. You say that you cannot get into bed or get the mail. You say that you cannot get 
to your appointments and that you have magnetic resonance imaging (MRI) services coming up. The Plan 
denied your request. The Plan says the records do not show that the enrollee's weight is between 285 and 400 
pounds. The Plan says that the records do not show why the requested accessories are medically necessary for 
use on the enrollee's wheelchair. 
 
The Plan must follow Medicare rules. Medicare rules say that a power wheelchair is only covered if the 
beneficiary's weight is less than or equal to the weight capacity of the power wheelchair that is provider and 
greater than or equal to 95% of the weight capacity of the next lower weight class power wheelchair. The rules 
also say that if the power wheelchair base is not covered, then related accessories will be denied. 
 
 
 We looked at the file and Medicare rules. The records show that the enrollee is requesting coverage of code 
K0824, which is defined as a group 2 heavy duty power wheelchair with a patient weight capacity of 301 to 
450 pounds. The records show that you weighed 280 pounds at the time of the request. This means that you do 
not meet the weight range listed in the coverage criteria for a heavy-duty wheelchair. Because the power 
wheelchair base is not covered, the related supplies you requested are also non-covered. Therefore, we decided 
that the Plan does not have to pre-approve a group 2 heavy duty power wheelchair represented by code K0824, 
a cup holder, a side bag, and a bracket represented by code K0108.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care. 
 
You asked the Plan to pre-approve SNF care. You say that you are a fall risk. The Plan denied your request. 
The Plan says you can be treated at a lower level of care. 
 
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 you do not have any parental medication, 
complex wound care, or nutrition given via a feeding tube.  You are medically stable without any acute 
exacerbations of chronic medical problems. Your physical function is at or near you baseline and you can 
receive services 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 have not been met. Therefore, we decided that the Plan does not have 
to pre-approve skilled nursing facility (SNF) care.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the arthrocentesis procedure and synvisc 
injection (J7325, 20610) provided on December 2, 2021. 
 
You asked the Plan to waive the copayment for the arthrocentesis procedure and synvisc injection. 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 hospital services and a 20% coinsurance for Medicare-covered Part B drugs and the 
administration of them. 
 You have been asked to pay a $30 copayment for an arthrocentesis procedure and a 20% coinsurance for a 
synvisc injection (allowed is $788.64 x 20% = $157.73). Arthrocentesis procedures and synvisc injections fall 
within the Outpatient hospital 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 
the arthrocentesis procedure and synvisc injection (J7325, 20610) provided on December 2, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit provided on July 26, 2021, by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for the office visit. You say that you were unaware that an authorization was needed. 
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 an office visit provided on July 26, 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 evaluation and management services provided on 
November 29, 2021. 
 
You asked the Plan to pay for the services provided. You say that the code must be reported separately. The 
Plan denied your request. The Plan says the claim was billed with an invalid 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 99417 is prolonged office or other outpatient evaluation 
and management service(s) beyond the minimum required time of the primary procedure which has been 
selected using total time, requiring total time with or without direct patient contact beyond the usual service, on 
the date of the primary service, each 15 minutes of total time (List separately in addition to codes 99205, 99215 
for office or other outpatient Evaluation and Management services). 
 
We find that CPT code 99417 is not valid for Medicare purposes. Medicare uses another code for the reporting 
of, and payment for, these services. Based on this information, we decided that Medicare rules for coverage 
have not been met. Therefore, we decided that the Plan does not have to pay for the evaluation and 
management services provided on November 29, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a semi-electric hospital bed (E0260). 
 
You asked the Plan to pre-approve a semi-electric hospital bed. You say that the item is medically necessary. 
The Plan denied your request. The Plan says this item is not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that a semi-electric hospital bed may be considered 
medically necessary when the patient: 
 
1. Has a medical condition which requires positioning of the body in ways not feasible with an ordinary bed; or 
 2. Requires attachments which can only be attached to a hospital bed; AND 
 
3. Requires frequent changes in body position and/or has an immediate need for a change in body position. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve a semi-electric hospital bed. Our 
reviewer says that this item is not medically necessary. Our physician reviewer found the documentation 
submitted does not reveal a need for frequent or immediate need for a change in body position. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of a semi-electric hospital bed have not been met. Therefore, we decided that the 
Plan does not have to pre-approve a semi-electric hospital bed (E0260).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for collection of blood from an implantable venous access 
device (36591) provided on November 15, 2021. 
 
You asked the Plan to pay for blood draw 36591. You say that this code was underpaid. The Plan denied your 
request. The Plan says the denial of payment for this code is correct, because code 36591 is not separately 
payable per the outpatient prospective payment system. 
 
The Plan must follow Medicare rules. Medicare rules say that code 36591 is packaged for payment when billed 
in the presence of any payable code with Status Indicator S, T, or V.  
 
We looked at the file and Medicare rules. This code was billed in the presence of other paid codes which had a 
Status Indicator of S, for example code 96367 and code 96375. Therefore, code 36591 is packaged for payment 
and is not separately paid. Based on this information, we decided that Medicare rules for coverage of blood 
draw 36591 have not been met. Therefore, we decided that the Plan does not have to pay for collection of blood 
from an implantable venous access device (36591) provided on November 15, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the inpatient services provided from April 16, 2021, to April 
19, 2021 outside of the United States. 
 
You asked the Plan to pay for the inpatient services. You say that you were told that the enrollee would be 
reimbursed something for the amount they paid, but ended up getting nothing. The Plan denied your request. 
The Plan says the billed services were rendered outside the continental United States. The Plan contract says 
that services rendered outside of the US and its territories are not covered. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services furnished outside the United 
States are excluded from coverage except for the services listed in the Rules section above.  
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the inpatient services have not been met. Therefore, we decided that the Plan does not have to pay 
for the inpatient services provided from April 16, 2021, to April 19, 2021 outside of the United States.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the chest x-ray (71046) provided on October 20, 2021. 
 
You asked the Plan to pay for the chest x-ray. You say that you would like reconsideration based on the records 
submitted. The Plan denied your request. The Plan says payment for this service would be included in the 
facility payment and the responsibility of the facility. 
 
The Plan must follow Medicare rules. Medicare rules say that diagnosis code Z01.818 does not support the 
medical necessity of a chest x-ray. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the chest x-ray have not been met. Specifically, the documentation supports that this service was 
rendered for pre-operative clearance. Tests provided without signs or symptoms are considered screening and 
not covered. Additionally, per the LCA, the diagnosis code billed on the claim does not support the medical necessity of the chest x-ray. Therefore, we decided that the Plan does not have to pay for the chest x-ray 
(71046) provided on October 20, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for laboratory services (87798, 87481, 87640, 87651, 87653) 
provided on December 19, 2021, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for laboratory services. You say that the services rendered should not require pre-
authorization since you are a participating provider. The Plan denied your request. The Plan says this provider 
is not a network provider with the Plan. The Plan also said that based on the documentation submitted, they 
have determined that the services rendered to the member are not urgent or emergent, nor were they approved 
in advance by a network provider. 
 
 
 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 (87798, 87481, 87640, 87651, 
87653) provided on December 19, 2021, by an out-of-network (OON) provider.