Persius/hicric huggingface dataset:
Appeal type: Outpatient Mental Health
Decision: Favorable

 
We decided that the Plan has to pay for the individual psychotherapy services (90832) provided October 28, 
2021. 
 
You asked the Plan to pay for the psychotherapy services. You say that please review the attached document 
and process the claim towards payment. The Plan denied your request. The Plan says that the services is not 
supported without the required documentation. 
 
The Plan must follow Medicare rules. Medicare rules say that if the patient consents, you must attempt to 
consult their attending or primary care physician about provided services and either document consent or 
declination date to consultations and date of consultations in patients medical record. If consultations are 
unsuccessful, document the patients medical chart with the date and physician notification method.  
 
We looked at the file, and Medicare rules. The submitted claim includes a referring provider for the services at 
issue. Documentation of a physician consultation does not apply when the physician has referred the 
beneficiary to the clinical psychologist.  Based on this information, we decided that Medicare rules for 
coverage of the psychotherapy services have been met. Therefore, we decided that the Plan has to pay for the 
individual psychotherapy services (90832) provided October 28, 2021.  
 
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again 
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake 
and/or send us the new information. This does not happen often. If we decide to open the case again, we will 
send you a letter.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission 
and services. to be provided by an out-of-network (OON) facility. 
 
You asked the Plan to pre-approve IRF care. You say that you are aware of the in-network facility availability. 
You also say that the OON facility is the facility of choice and was recommended by the neurosurgeon who 
believes that the facility can provide comprehensive therapeutic intervention given the enrollee's diagnosis. The 
Plan denied your request. The Plan says the requested IRF facility is OON and does not participate in the 
enrollee's Medicare Plan. Upon enrolling, the enrollee agreed to use network providers to get medical care and 
services. The Plan also says the enrollee does not live at this facility, this is not a continuity of care and the 
Plan has found providers 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 pre-approve care from out-of-network providers only in cases involving 
emergencies, out of area urgent care and care that cannot be provided by network providers. 
 
 
 The requested provider in this case is not a network provider with the Plan. The Plan has network providers 
available who can provide the items/services at issue in this appeal. We found no exception that would require 
the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve 
acute inpatient rehabilitation facility (IRF) admission and services. to be provided by an out-of-network (OON) 
facility.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the COVID-19 vaccine and administration (91301, 0012A) 
provided on May 5, 2021. 
 
You asked the Plan to pay for the COVID-19 vaccine. You say that you would like to be reimbursed for the 
vaccine and administration. The Plan denied your request. The Plan says this claim must be submitted to 
original Medicare. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly.  
 
Pursuant to CMS guidance Medicare payment for COVID vaccinations administered during calendar years 
2020 and 2021 to MA beneficiaries will be made through the Medicare Fee for Service program. Based on this 
information, we decided that Medicare rules for coverage of the COVID-19 vaccine have not been met. Therefore, we decided that the Plan does not have to pay for the COVID-19 vaccine and administration (91301, 
0012A) provided on May 5, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services provided on June 2, 2021. 
 
You asked the Plan to pay for the lab services. You say that you billed these services correctly. The Plan denied 
your request. The Plan says you billed an incorrect place of service on the claim. 
 
The Plan must follow Medicare rules. Medicare rules say that lab services, the POS code must reflect the 
location in which the sample was taken. POS code 81 is used to describe samples taken by the laboratory 
directly.  
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the 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 June 2, 2021.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the therapeutic procedure (CPT code 97110) provided on 
October 7, 2021. 
 
You asked the Plan to pay for the service. You say that the claim should be paid. The Plan denied your request. 
The Plan says the service is not covered as 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. 
 
CPT code 97110 GP CQ KX (4 units) remains not supported. CPT code represents Therapeutic procedure, 1 or 
more areas, each 15 minutes; therapeutic exercises to develop strength and endurance, range of motion and 
flexibility, however the records indicate that the service is performed by a physical therapist assistant in a home 
health or hospice setting. Of note there is an appropriate Healthcare Common Procedure Coding System 
(HCPCS) code (G0157) for the billed service. It is noted that multiple attempts were made to contact the 
provider for additional information.  Based on this information, we decided that Medicare rules for coverage of 
the service have not been met. Therefore, we decided that the Plan does not have to pay for the therapeutic 
procedure (CPT code 97110) provided on October 7, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve LTACH services. 
 
You asked the Plan to pre-approve the LTACH services. You say that the enrollee has had a very long, 
complicated hospital course, and it is your strong recommendation that they be approved for admission to 
LTACH level of care. The Plan denied your request. The Plan says the enrollee does not meet Medicare criteria 
for coverage. 
 
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically 
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 
 
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 LTACH services. Our reviewer says 
that the requested LTACH care is not considered medically reasonable and necessary in this case. Our 
physician reviewer found the enrollee appears to be improving and should only require short-term additional 
acute care services that can safely be administered at the current facility. 
 
 
 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 LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve LTACH services.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services rendered on August 15, 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 claims must be billed with the correct place of 
service (POS) code. 
 
We looked at the file and Medicare rules. The claim for these services was billed with POS code 81 for a 
laboratory setting; however, the file shows that the specimen was obtained in an office setting and should have 
been billed with POS code 11. Therefore, we decided that the Plan does not have to pay for the laboratory 
services rendered on August 15, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the lab services provided on March 18, 2021. 
 
You asked the Plan to pay for the lab services. You say that all specimens are sent to the facility by the 
enrollee's physician. The Plan denied your request. The Plan says the codes remain not supported. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate code. The claim billed a place of service as 81, an independent laboratory. We looked at the file and the rules. If an 
independent lab bills for services, the place where the sample was taken is reported as the place of service. The 
records do not show that the specimen was obtained at the independent laboratory. 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 lab services provided on March 18, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory service (CPT code 81479) provided on 
September 1, 2021. 
 
You asked the Plan to pay for the laboratory service. You say that the claim should be paid. The Plan denied 
your request. The Plan says the service is not covered as billed. 
 
The Plan must follow Medicare rules. We looked at the file and Medicare rules. Based on this information, we 
decided that Medicare rules for coverage of the laboratory service have not been met. CPT code 81479 remains 
not supported. The place of service on the CMS-1500 form line 24B must reflect the location of the patient 
when the specimen was obtained. The submitted claim form indicates the laboratory specimen was obtained in 
a laboratory, POS 81; however, the submitted medical documentation and/or claim history indicates that the 
specimen was obtained in an office setting POS 11; therefore, the billed code cannot be verified. It is noted 
multiple attempts were made to obtain additional information from the provider. Therefore, we decided that the 
Plan does not have to pay for the laboratory service (CPT code 81479) provided on September 1, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the office visit (CPT code 99202-95) provided on March 5, 
2021. 
 
You asked the Plan to pay for the services. You say that the claim should be paid. The Plan denied your 
request. The Plan says research of claims history was unable to substantiate an established relationship with 
this provider or group. The Plan states this provider is engaged in a Telemarketing Scheme and the enrollee has 
no knowledge of billing Provider. The Plan states they are upholding for no established relationship with the 
ordering provider also requested documentation was not received from the ordering provider. 
 
The Plan must follow Medicare rules. Medicare rules say that the provider, supplier, or beneficiary, as 
appropriate, must furnish to the intermediary or carrier sufficient information to determine whether payment is 
due and the amount of payment. 
 We looked at the file and Medicare rules. Based on this information, we decided that there is insufficient 
information in the record to determine if Medicare rules for coverage of the office visit Current Procedural 
Terminology (CPT) code 99202-95) provided on March 5, 2021. have been met. The medical records were not 
provided. Therefore, we decided that the Plan does not have to pay for the office visit (CPT code 99202-95) 
provided on March 5, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a manual wheelchair with elevating leg rests and an 
anti-tipping device. 
 
You asked the Plan to pre-approve the services. You say that this is medically necessary. The Plan denied your 
request. The Plan says there is no documentation to support a need for this kind of wheelchair. 
 
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 there is no documentation of a personal mobility deficit that impairs participation in mobility-related 
activities of daily living, such as toileting, feeding, grooming and bathing in customary locations within the 
home. There is no documentation of a  mobility deficit that cannot be helped by the use of a walker or cane. 
The provided records do not address the appropriateness of the home for this wheelchair, or if you or a 
caregiver could propel the wheelchair. There is no mention of a need for specifically the K0004 wheelchair, the 
elevating leg rests, or the anti-tipping device. 
 
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 manual wheelchair with elevating leg rests and an anti-tipping device.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the wheelchair accessories. 
 
You asked the Plan to pre-approve the wheelchair accessories. You say that the items are medically necessary. 
The Plan denied your request. The Plan says medical records were not submitted to determine medical 
necessity of the requested items. 
 
The Plan must follow Medicare rules. Medicare rules say that for Medicare to consider coverage and payment 
for any item or service, the information submitted by the supplier or provider must corroborate the 
documentation in the beneficiary's medical documentation and confirm that Medicare coverage criteria have 
been met. 
 
We looked at the file and Medicare rules. Based on this information, we decided that there is insufficient 
information in the record to determine if Medicare rules for coverage of the wheelchair accessories have been 
met. Medical records were not submitted and we are unable to determine medical necessity of the requested 
items.. Therefore, we decided that the Plan does not have to pre-approve the wheelchair accessories.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the outpatient office visit (99202) provided March 12, 2021. 
 
You asked the Plan to pay for the office visit. You say that kindly review the attached medical records and 
process towards payment. The Plan denied your request. The Plan says there is evidence of misrepresented 
services. 
 
The Plan must follow Medicare rules. Medicare rules say that the provider, supplier, or beneficiary, as 
appropriate, must furnish to the intermediary or carrier sufficient information to determine whether payment is 
due and the amount of payment. 
 
We looked at the file and Medicare rules. Based on this information, we decided that there is insufficient 
information in the record to determine if Medicare rules for coverage of the outpatient office visit (99202) 
provided March 12, 2021 have been met. There is no evidence of an established relationship between the enrollee and the physician. The Plan also had 
requested additional records from the provider without success. Therefore, we decided that the Plan does not 
have to pay for the outpatient office visit (99202) provided March 12, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services rendered on September 29, 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 procedure code 84481 is not separately payable. 
 
The rules say that if the modifier indicator is 0, the Column 2 code cannot be paid regardless of whether a 
modifier is used. 
 
We looked at the file and Medicare rules. The provider submitted a claim for procedure codes 84481 (free 
assay [FT-3]) and 84480 (triiodothyronine [T3] assay). Code 84481 is a column II code with a modifier 
indicator of 0 when billed with column I code 84480. No separate payment is made for code 84481. Therefore, 
we decided that the Plan does not have to pay for the laboratory services rendered on September 29, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the periodic comprehensive preventive medicine 
reevaluation and management services coded 99397 provided on June 22, 2021. 
 
You asked the Plan to pay for the preventive medicine services. You say that you would like this claim 
reprocessed and approved for payment. The Plan denied your request. The Plan says this code is not eligible for 
payment according to Medicare rules. 
 
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 99397 is periodic comprehensive preventive medicine 
reevaluation and management of an individual including an age and gender appropriate history, examination, 
counseling/anticipatory guidance/risk factor reduction interventions, and the ordering of laboratory/diagnostic 
procedures, established patient; 65 years and older. 
 
We looked at the file and Medicare rules. Specifically, this code has a Payment Status Indicator of E1 under 
the Hospital Outpatient Prospective Payment System (PPS). This Payment Status Indicator indicates that this 
code will not be paid by Medicare when submitted on an outpatient claim. Based on this information, we decided that Medicare rules for coverage of the preventive medicine services have not been met. Therefore, we 
decided that the Plan does not have to pay for the periodic comprehensive preventive medicine reevaluation 
and management services coded 99397 provided on June 22, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the supervision of a nursing facility patient (99379) provided 
on August 1, 2021. 
 
You asked the Plan to pay for the supervision of a nursing facility patient (99379). You say that the physician 
provided medically necessary services and the services rendered meet standards of healthcare. You say that the 
claim should be processed for payment. The Plan denied your request. The Plan says bundled services are not 
eligible for separate reimbursement. 
 
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 99379 is supervision of a nursing facility patient (patient 
not present) requiring complex and multidisciplinary care modalities involving regular development and/or 
revision of care plans by that individual, review of subsequent reports of patient status, review of related 
laboratory and other studies, communication (including telephone calls) for purposes of assessment or care 
decisions with health care professional(s), family member(s), surrogate decision maker(s) (eg, legal guardian) 
and/or key caregiver(s) involved in patient's care, integration of new information into the medical treatment 
plan and/or adjustment of medical therapy, within a calendar month; 15-29 minutes. 
 
We find that CPT code 99379 is not supported in the medical record. Specifically, CPT code 99379 has a status 
indicator of B. This means that CPT code 99379 is considered bundled and not separately payable. Based on 
this information, we decided that Medicare rules for coverage of the supervision of a nursing facility patient 
(99379) have not been met. Therefore, we decided that the Plan does not have to pay for the supervision of a 
nursing facility patient (99379) provided on August 1, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the annual wellness visit provided on August 23, 2021. 
 
You asked the Plan to pay for the services provided. You say that you only saw the nurse practitioner. The Plan 
denied your request. The Plan says you already had this exam done. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance).  
 
The file shows that you received an annual wellness visit on August 23, 2021. You previously received this 
service on June 11, 2021. We looked at the file and the rules. This type of visit is only covered once every 
calendar year. The services fall within the annual wellness visit benefit category. This means that you have 
been asked to pay the correct amount based on your contract with the Plan. Therefore, we decided that the Plan 
does not have to pay for the annual wellness visit provided on August 23, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that you disagree with the Plan's denial. The Plan denied 
your request. The Plan says you do not meet Medicare criteria for coverage. 
 
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. Our 
physician reviewer found your rehabilitation needs can be met at a lower intensity setting such as in-home or in 
a skilled nursing facility. 
 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 IRF admission and services.