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

 
We decided that the Plan does not have to pay for an office visit (99212) provided on December 1, 2021, by an 
out-of-network (OON) provider. 
 
You asked the Plan to pay for an office visit. You say that you are in network and should not need an 
authorization. The Plan denied your request. The Plan says this provider is not a network provider with the Plan 
and no referring provider was found. The Plan also says that they have also determined that these services are 
not urgent or emergent, nor were they 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 an office visit (99212) provided on December 1, 
2021, by an out-of-network (OON) provider.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the retroperitoneal ultrasound (76770) provided on 
November 21, 2021. 
 
You asked the Plan to pay for the ultrasound. You say that the enrollee had multiple exams performed on this 
date. The Plan denied your request. The Plan says a National Correct Coding Initiatives (NCCI) Procedure to 
Procedure (PTP) edit exists between 93975 and 76770. This PTP edit has a modifier indicator of 1, meaning modifiers associated with NCCI are allowed. However, an appropriate modifier was not billed with this PTP 
code edit. This service was not billed as required by Medicare coding regulations. 
 
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 76770 
is a column II code to column I code 93975. 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 the retroperitoneal ultrasound (76770) provided on November 
21, 2021.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for imaging services provided to the enrollee on November 18, 
2021. 
 
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. 
The Plan says the provider did not bill as required by Medicare coding regulations. 
 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 70450 
is a column II code to column I code 70496. 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 imaging services provided to the enrollee on November 18, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the office visit (99202) provided on February 18, 2021. 
 
You asked the Plan to pay for the office visit. You say that you would like reconsideration based on the records 
submitted. The Plan denied your request. The Plan says there is not an established relationship between the 
member and ordering physician. 
 
The Plan must follow Medicare rules. Medicare rules say that unless provided otherwise, other services 
included on the Medicare telehealth services list must be furnished using, at a minimum, audio and video equipment permitting two-way, real-time interactive communication between the patient and distant site 
physician or practitioner.  
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the office visit have not been met. Specifically, the documentation does not clearly indicate that the 
service was furnished using audio and video equipment permitting two-way, real-time interactive 
communication between the patient and distant site physician or practitioner. CPT code 99202 is not included 
on the list of codes which are appropriate for audio-only telehealth services. The documentation does not 
clearly show if this service was furnished using audio-only or audio-video communication. Therefore, we 
decided that the Plan does not have to pay for the office visit (99202) provided on February 18, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services provided on August 17, 2021. 
 
You asked the Plan to pay for the laboratory services. You say that you would like the Plan to reconsider their 
denial of payment. The Plan denied your request. The Plan says the services are not covered as billed.  
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. 
 
We looked at the file and Medicare rules. Review of the file shows the claim was billed with an inappropriate 
place of service 11. According to claims history, the specimen was obtained in a Community Mental Health 
Center. Therefore, we decided that the Plan does not have to pay for the laboratory services provided on 
August 17, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the foot orthotics rendered on September 4, 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 provider is not Medicare-certified. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for services only when they are 
furnished by a provider or supplier enrolled in the Medicare program. 
 
We looked at the file and Medicare rules. The file shows that the provider was not Medicare-certified for the 
date of service at issue. Therefore, we decided that the Plan does not have to pay for the foot orthotics rendered 
on September 4, 2021.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for routine ambulance supplies (A0382, A0394, A0938) 
received on November 16, 2021. 
 
You asked the Plan to pay for the supplies. You say that you have been having this problem for months. The 
Plan denied your request. The Plan says these services are not paid separately. 
 
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 ambulance supply codes A0382, A0394, A0938 are not supported in the medical record. 
Specifically, ambulance supplies are considered inclusive and are generally bundled into payment for other 
codes. Based on this information, we decided that Medicare rules for coverage of the supplies have not been 
met. Therefore, we decided that the Plan does not have to pay for routine ambulance supplies (A0382, A0394, 
A0938) received on November 16, 2021.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pay for therapeutic exercises (97110) provided on August 30, 2021. 
 
You asked the Plan to pay for therapeutic exercises. You say that these services were medically necessary and 
were billed correctly. The Plan denied your request. The Plan says these services are not supported as billed. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
 
We find that CPT code 97110 is not supported in the medical record. Specifically, the documentation shows 
that this claim was billed by a Nurse Practitioner but the therapy services at issue were rendered by a Physical 
Therapy Assistant. There is no indication that the Nurse Practitioner was present on site while the therapy 
services were being rendered. The incident-to requirements have not been met in this case. Based on this 
information, we decided that Medicare rules for coverage of therapeutic exercises have not been met. 
Therefore, we decided that the Plan does not have to pay for therapeutic exercises (97110) provided on August 
30, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the segmental gradient pressure pneumatic appliance 
(E0673) provided August 11, 2021. 
 
You asked the Plan to pay for the pneumatic appliance. You say that you provided a service to the enrollee in 
good faith at the direction of the doctor's order and the necessity of the enrollee's health and recovery. 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 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 enrollee used the equipment in the facility during and/or after surgery. Payment for this service 
would have been included under the facility claim. Payment for this service is the responsibility of the facility 
or hospital that provided the surgery. Based on this information, we decided that Medicare rules for coverage of 
the pneumatic appliance have not been met. Therefore, we decided that the Plan does not have to pay for the 
segmental gradient pressure pneumatic appliance (E0673) provided August 11, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay an additional amount for eyewear provided on April 27, 2021. 
 
You asked the Plan to pay an additional amount for the eyewear. The Plan denied your request. The Plan says 
$21.24 of your $100 vision allowance was used on October 13, 2021 for your lenses. The vision claim from 
April 27, 2021 processed correctly as your full $100 allowance has been utilized. Therefore, you are 
responsible for the remaining $18.24 amount. 
 
Medicare generally does not cover routine eyewear services. However, the Plan offers a routine eyewear 
benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case.  We looked at the file and the Plan's rules. The file shows that the Plan has paid claims with the maximum 
eyewear benefit of a $100 allowance every two years. Therefore, we decided that the Plan does not have to pay 
an additional amount for eyewear provided on April 27, 2021.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve facet joint injections (64495, 64493, 64494). 
 
You asked the Plan to pre-approve the facet joint injections. You say that the services are medically necessary. 
The Plan denied your request. The Plan says coverage criteria has not been met. 
 
The Plan follows Medicare rules. Medicare rules say that Facet Joint interventions are covered when 
considered medically reasonable and necessary for the diagnosis and treatment of chronic pain. 
 
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 facet joint injections. Our reviewer 
says that the injections are not medically necessary. Our physician reviewer found the rationale for intra-
articular blocks is not explained and there is no anatomic abnormality defined by the records provided.  
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 facet joint injections have not been met. Therefore, we decided that the Plan 
does not have to pre-approve facet joint injections (64495, 64493, 64494).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the moderate sedation services rendered on June 24, 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 99152 is not supported. 
 
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 99152 is moderate sedation services by other qualified 
health care professional requiring the presence of an independent trained observer to assist in the monitoring of 
the patient's level of consciousness and physiological status, patient 5 years of age or older, first 15 minutes. 
 
We find that CPT code 99152 is not supported in the medical record. Specifically, there is no documentation of 
an independent trained observer to monitor the enrollee's level of consciousness and physiological status for the 
first 15 minutes. 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 moderate sedation services 
rendered on June 24, 2021.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pay for occupational therapy services (97530) provided on 
September 6, 2021. 
 
You asked the Plan to pay for occupational therapy services. You say that the services at issue were a medical 
necessity for the enrollee. The Plan denied your request. The Plan says rules for payment have not been met. 
 
The Plan must follow Medicare rules. Medicare rules say that the services of an OTA shall not be billed as 
services incident to a physician/NPPs service because they do not meet the qualifications of a therapist. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of occupational therapy services have not been met. Specifically, the documentation shows that this 
claim was billed by a nurse practitioner but the therapy services at issue were rendered by an Occupational 
Therapy Assistant.  
 A Nurse Practitioner cannot bill for the services of an Occupational Therapy Assistant because they do not 
meet the qualifications of a therapist. Therefore, we decided that the Plan does not have to pay for occupational 
therapy services (97530) provided on September 6, 2021.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for ambulance response and treatment, no transport (A0998) 
provided by Breck Central Ambulance, on October 11, 2021. 
 
You asked the Plan to pay for ambulance response and treatment, no transport. You say that your husband 
found you unconscious and he called 911 and an ambulance arrived at your home. You say that the ambulance 
technicians checked your blood glucose, and they gave you an injection of 50% Dextrose and you soon 
recovered. You say that emergency assistance was required. The Plan denied your request. The Plan says per 
Medicare guidelines, the ambulance benefit is a transport benefit. If there is no transport, then there is no 
Medicare-covered service. 
 
The Plan must follow Medicare rules. The rules say that Medicare does not pay for ambulance services when 
there is no transport.  
 
The ambulance company did not provide transport services on October 11, 2021. The ambulance benefit is a 
transportation benefit. When there is no transport, neither Medicare nor the Plan pays for the services provided. Therefore, we decided that the Plan does not have to pay for ambulance response and treatment, no transport 
(A0998) provided on October 11, 2021.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the vascular study (93976) provided on October 26, 2021. 
 
You asked the Plan to pay for the vascular study. You say that the enrollee received multiple exams on this 
date. The Plan denied your request. The Plan says a National Correct Coding Initiative (NCCI) Procedure to 
Procedure (PTP) edit exists between 93976 and 76856. This PTP edit has a modifier indicator of 1, which 
indicates that modifiers associated with the NCCI are allowed. However, an appropriate modifier was not billed 
with this PTP code edit. 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 93976 
is a column II code to column I code 76856. 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 the vascular study (93976) provided on October 26, 2021.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an echocardiography (93351) provided on 
November 8, 2021. 
 
You asked the Plan to waive the copayment for the echocardiography. You say that the services should be 
covered. 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 $155 
copayment for Outpatient Diagnostic Tests and Therapeutic Services and Supplies.  
 
 You have been asked to pay a $155 copayment for an echocardiography. Echocardiographys 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 echocardiography (93351) provided on November 8, 2021.
Appeal type: Hospice
Decision: Unfavorable

 
We decided that the Plan does not have to pay for physician's services provided on May 5, 2021. 
 
You asked the Plan to pay for the physician's services. The Plan denied your request. The Plan says Original 
Medicare would be responsible for payment of all Medicare covered services related or unrelated to the 
members terminal condition. The Medicare hospice benefit, through fee-for-service Medicare, covers all 
hospice care from the effective date of election to the date of discharge or revocation. During the election, fee-
for-service Medicare also covers attending physician services and all care unrelated to the terminal illness until 
the first day of the month following the month in which hospice was revoked or discharged. 
 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 physician's services provided on May 5, 2021.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the office visit (99202) provided on February 17, 2021.  
You asked the Plan to pay for the office visit. You say that you would like reconsideration based on the records 
submitted. The Plan denied your request. The Plan says there is no established relationship between the 
enrollee and ordering physician. 
 
The Plan must follow Medicare rules. Medicare rules say that unless provided otherwise, other services 
included on the Medicare telehealth services list must be furnished using, at a minimum, audio and video 
equipment permitting two-way, real-time interactive communication between the patient and distant site 
physician or practitioner. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the office visit have not been met. Specifically, the documentation does not clearly indicate that the 
service was furnished using audio and video equipment permitting two-way, real-time interactive 
communication between the patient and distant site physician or practitioner. CPT code 99202 is not included 
on the list of codes which are appropriate for audio-only telehealth services. The documentation does not 
clearly show if this service was furnished using audio-only or audio-video communication. Therefore, we 
decided that the Plan does not have to pay for the office visit (99202) provided on February 17, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a wound debridement procedure performed 
on October 18, 2021. 
 
You asked the Plan to waive the copayment for the wound debridement. You say that previous claims were 
overturned and you only paid a specialist copayment. The Plan denied your request. The Plan says you have 
been 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 $325 
copayment for surgery or other services provided at an outpatient hospital.  
 
 
 The file shows that for the previous claims, the Plan was unable to obtain records to confirm service location. 
The Plan overturned those claims. In this case, records were received, confirming the location as an outpatient 
hospital. Therefore, you have been asked to pay a $325 copayment for the wound debridement. The wound 
debridement falls within the Outpatient Surgery, Including Services Provided at Hospital Outpatient Facilities 
and Ambulatory Surgical Centers 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 a 
wound debridement procedure performed on October 18, 2021.