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

 
We decided that the Plan does not have to pay for the home injectable therapy (S9542) provided on July 26, 
2021. 
 
You asked the Plan to pay for the home injectable therapy (S9542). You say that these codes were authorized 
prior to treatment and the authorization is enclosed to reprocess the claim for correct payment. The Plan denied 
your request. The Plan says the billed code is not valid 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 CPT code. 
 
We find that CPT code S9542 has a Status Indicator of I on the Physician Fee Schedule. This means that CPT 
code S9542 is not valid for Medicare purposes. Based on this information, we decided that Medicare rules for 
coverage of the home injectable therapy (S9542) have not been met. Therefore, we decided that the Plan does 
not have to pay for the home injectable therapy (S9542) provided on July 26, 2021.
Appeal type: Hospice
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the gauze (A6219) and collagen based wound filler (A6010) 
provided on November 16, 2021. 
 
You asked the Plan to pay for the wound care. You say that wound care supplies are a Medicare Part B benefit. 
You also say that they are separately reimbursable expense that does not require separate authorization. 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 gauze (A6219) and collagen based wound filler (A6010) 
provided on November 16, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the special anesthesia service (99100) provided on May 19, 
2021. 
 
You asked the Plan to pay for the special anesthesia service (99100). You say that this is a different site than 
the arterial line placed for anesthesia and payment should be reconsidered. The Plan denied your request. The 
Plan says procedure code 93313 has been overturned and procedure code 99100 remains denied as 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. 
 
We find that CPT code 99100 has a status indicator of B on the Physician Fee Schedule. This means that CPT 
code 99100 is not separately payable. Based on this information, we decided that Medicare rules for coverage 
of the special anesthesia service (99100) have not been met. Therefore, we decided that the Plan does not have 
to pay for the special anesthesia service (99100) provided on May 19, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the acupuncture (98710), provided on November 23, 2021, 
through November 30, 2021. 
 
You asked the Plan to pay for the acupuncture. You say that the service should be covered. The Plan denied 
your request. The Plan says you have exhausted the Plan benefit for this service. 
 
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. However, your Plan offers coverage beyond the Medicare acupuncture benefit. As such, the Plans rules apply in this case.  
 
We looked at the file and Medicare rules. Based on this information, we decided that the rules for coverage of 
the acupuncture services have not been met. Specifically, the records indicate you have used all of the allowed 
20 visits, making any additional visits your responsibility. Therefore, we decided that the Plan does not have to 
pay for the acupuncture (98710), provided on November 23, 2021, through November 30, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a group 2 power wheelchair (K0823). 
 
You asked the Plan to pre-approve a group 2 power wheelchair. You say that the item is medically necessary. 
The Plan denied your request. The Plan says the item is not medically necessary. 
 
The Plan follows Medicare rules. Medicare rules say that all the criteria listed in the Medicare Rules section 
must be met for coverage of this item. 
 
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 group 2 power wheelchair. Our 
reviewer says that you do not need this item. Our physician reviewer found the clinical documentation 
submitted indicates you are ambulatory with cane/walker. 
 
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 group 2 power wheelchair have not been met. Therefore, we decided that the 
Plan does not have to pre-approve a group 2 power wheelchair (K0823).
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the inpatient hospital services provided 
from April 22, 2021, to May 3, 2021. 
 
You asked the Plan to waive the copayment for the inpatient hospital services. You say that you feel the 
enrollee should not pay for the extra days he had to stay at the hospital. The Plan denied your request. The Plan 
says the copayment amount the enrollee is being charged is correct. 
 
  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 enrollees contract with the Plan clearly says that enrollees 
must pay a $320 copayment per day for days 1 to 6, and a $0 copayment per day for days 7 to 90 for Inpatient 
hospital care.  
 
The enrollee has been asked to pay a $320 copayment per day for days 1 to 6, and a $0 copayment per day for 
days 7 to 90 for the inpatient hospital services, totaling the amount of $1,920.00. The inpatient hospital services 
fall within the Inpatient hospital care benefit category. This means that the enrollee has been asked to pay the 
correct amount based on the contract with the Plan. This cost sharing is a contractual obligation the enrollee 
agreed to pay upon enrolling in the Plan. Therefore, we decided that the Plan does not have to waive the 
copayment for the inpatient hospital services provided from April 22, 2021, to May 3, 2021.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ambulance response and treatment, no transport, (A0998) 
provided on October 30, 2021. 
 
You asked the Plan to pay for the ambulance service. You say that although you were not transported, you were 
treated for your injury. You also say that you feel the provider is deserving of some remittance by your 
insurance. The Plan denied your request. The Plan says since there was not transport provided, there is no 
payable 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 30, 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 the ambulance response and treatment, no 
transport, (A0998) provided on October 30, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a knee brace (L1845). 
 
You asked the Plan to pre-approve a knee brace. You say that the item is medically necessary. The Plan denied 
your request. The Plan says there is no documentation of a recent injury, surgery, or instability to the knee. 
 
The Plan must follow Medicare rules. Medicare rules say that Claims for L1832, L1833, L1843, L1845, L1850, 
L1851 or L1852 will be denied as not reasonable and necessary when the beneficiary does not meet the criteria for coverage. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of a knee brace have not been met. Specifically, your doctor's exam noted full flexion and extension 
of the right knee and no instability. Therefore, we decided that the Plan does not have to pre-approve a knee 
brace (L1845).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the eye exam (92002), frames (V2020), and progressive lens, 
per lens (V2781) provided on January 13, 2022 by an out-of-network (OON) provider.  
You asked the Plan to pay for the eye exam, frames, and progressive lens. You say that you have been working 
with this supplier and doctors for over 10 years, and they have your records. You also say that in-network 
providers have not in the past been able to provide the products and service that this treating provider has. The 
Plan denied your request. The Plan says your plan covers basic routine vision hardware from an in-network 
provider only and does not allow for OON coverage. 
 
Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine 
vision and eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in 
this case. The Plan covers these services when plan approved providers are used to receive benefits. 
 
We looked at the file and the Plan's rules. Specifically, you received these services from an OON provider who 
is not plan approved. Based on this information, we decided that the Plan's rules for coverage of the eye exam, 
frames, and progressive lens have not been met. Therefore, we decided that the Plan does not have to pay for 
the eye exam (92002), frames (V2020), and progressive lens, per lens (V2781) provided on January 13, 2022 
by an out-of-network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the eye exam (92014) and determination of refractive state 
(92015) provided on February 14, 2022. 
 
You asked the Plan to pay for the eye exam and determination of refractive state. You say that the replacement 
of your old eyeglasses required a new prescription. The Plan denied your request. The Plan says the eye 
refraction service is not a covered benefit since it was medical vision check. The Plan also says that eye 
refractions are only covered by the Plan if performed by a participating approved provider and performed as a 
routine screening, in addition there is a $35.00 copay for each specialist visit such as an ophthalmologist or 
optometrist. 
 
Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine 
vision and eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in 
this case. The Plan covers these services when performed by an approved routine vision care provider. 
 
We looked at the file and the Plan's rules. The record shows that these services were not rendered by an 
approved vision care provider, and you are responsible for a $35 copayment because the service was rendered 
by an optometrist. Based on this information, we decided that the Plan's rules for coverage of the eye exam and 
determination of refractive state have not been met. Therefore, we decided that the Plan does not have to pay 
for the eye exam (92014) and determination of refractive state (92015) provided on February 14, 2022.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve additional physical therapy provided by a participating 
provider. 
 
You asked the Plan to pre-approve physical therapy. You say that 13 additional physical therapy sessions are 
medically necessary. The Plan denied your request. The Plan says not enough medical record information was 
provided to verify additional PT visits are medically necessary. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for medically necessary outpatient 
therapy. 
 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 physical therapy. Our reviewer says 
that skilled services are not necessary to restore or maintain function or to prevent deterioration of the enrollee's 
condition. Our physician reviewer found the documentation does not reveal objective physical exam deficits or 
functional deficits. The documentation is not clear on any prior therapy the patient has had approved and the 
outcome. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of physical therapy have not been met. Therefore, we decided that the Plan does 
not have to pre-approve additional physical therapy provided by a participating provider.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the abdominal ultrasound (76705) provided on January 11, 
2022. 
 
You asked the Plan to pay for the ultrasound. You say that the enrollee had multiple exams on the date in 
question. The Plan denied your request. The Plan says a National Correct Coding Initiatives (NCCI) Procedure 
to Procedure (PTP) edit exists between 93976 and 76705. 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 appropriately 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 76705 
is a column II code to column I code 93976. 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 abdominal ultrasound (76705) provided on January 11, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve foot orthotics. 
 
You asked the Plan to pre-approve foot orthotics. You say that some days your heel is hurting so bad you can 
barely walk. The Plan denied your request. The Plan says this item is not a covered benefit. 
 
Medicare rules state that supportive devices for the feet (such as orthotics) are only covered for patients with 
diabetic foot disease or for patients who wear a leg brace. The Plan follows these same rules.   
 
Records show that you do not suffer from diabetic foot disease, and you do not wear a leg brace. Although 
orthotics may be appropriate for you, neither Medicare nor the Plan provides coverage of orthotics for your 
condition. Therefore, we decided that the Plan does not have to pre-approve foot orthotics.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a pneumatic compression device (E0650), segmental 
gradient pressure pneumatic appliance (E0673) and high-pressure pneumatic compression device (E0675). 
 
You asked the Plan to pre-approve the intermittent limb compression devices. You say that these items are 
medically necessary. The Plan denied your request. The Plan says pneumatic compression devices are not 
covered by Medicare for peripheral artery disease and deep venous thrombosis. 
 
The Plan follows Medicare rules. The rules state that Medicare covers pneumatic devices when medically 
necessary for the treatment of lymphedema and/or for the treatment of chronic venous insufficiency with 
venous stasis ulcers. 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. 
 The file does not show that the enrollee has lymphedema and/ or chronic venous insufficiency with venous 
stasis ulcers. In addition, E0675 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. Finally, as the base PCD cannot be approved the accessory E0673 will be denied. 
Therefore, we decided that the Plan does not have to pre-approve a pneumatic compression device (E0650), 
segmental gradient pressure pneumatic appliance (E0673) and high-pressure pneumatic compression device 
(E0675).
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the unlisted ambulance service (A0999) provided on 
September 28, 2021. 
 
You asked the Plan to pay for the ambulance service. You say that the service should be covered. The Plan 
denied your request. The Plan says that there is no agreement between the ALS and BLS providers. The Plan 
also says that there was no transport provided. 
 
The Plan must follow Medicare rules. 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 under a contract with a qualified basic life support (BLS), the provision of medically 
necessary supplies and services, with a volunteer ambulance company. In addition, State law must not allow 
the volunteer ambulance company to bill for the transport or BLS services.  
 
The Plan has confirmed that the ALS ambulance provider does not have a contract with the volunteer 
ambulance company that provided the transport services. Therefore, we decided that the Plan does not have to 
pay for the unlisted ambulance service (A0999) provided on September 28, 2021.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the abdominal ultrasound (76705) provided on January 1, 
2022. 
 
You asked the Plan to pay for the ultrasound. You say that the enrollee had multiple exams on the date in 
question. The Plan denied your request. The Plan says a National Correct Coding Initiatives (NCCI) Procedure 
to Procedure (PTP) edit exists between 93976 and 76705. 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 appropriately 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 76705 
is a column II code to column I code 93976. 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 abdominal ultrasound (76705) provided on January 1, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory work provided on November 29, 2021, to 
January 18, 2022, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for the laboratory work. You say that you were told the facility was in-network and 
that the labs were covered due to the coronavirus pandemic. You say you were never told that the coronavirus 
waiver was expired. The Plan denied your request. The Plan says no prior authorization was obtained. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
 The requested provider in this case is not a network provider with the Plan. The Plan had network providers 
available who could have provided the laboratory work at issue in this appeal. The Plan did not pre-approve the 
laboratory. We found no exception that would require the Plan to pay for the laboratory work. Therefore, we 
decided that the Plan does not have to pay for the laboratory work provided on November 29, 2021, to January 
18, 2022, by an out-of-network (OON) provider.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for intravenous (IV) infusions and a ferric 
carboxymaltose injection provided on December 10, 2021, and December 17, 2021.  
 
You asked the Plan to waive the coinsurance for IV infusions and an injection. You say that you were never 
told that the hospital was not covered by the insurance plan. You also say that you cannot afford to pay this bill. 
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 30% 
coinsurance for out-of-network Part B drugs and administration.  
 
 
 The record shows these claims were approved, and you have a cost sharing amount. You have been asked to 
pay a total of $649.84 for IV infusions and an injection. IV infusions and an injection fall within the Medicare 
Part B Prescription Drugs benefit category.  
 
Date of Service Code Allowed Amount 30% Coinsurance 
December 10, 2021 96365 $243.06 $72.92 
December 10, 2021 J1439 $840.00 $252.00 
December 17, 2021 96365 $243.06 $72.92 
December 17, 2021 J1439 $840.00 $252.00 
Total   $649.84 
 
This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost 
sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that 
the Plan does not have to waive the coinsurance for intravenous (IV) infusions and a ferric carboxymaltose 
injection provided on December 10, 2021, and December 17, 2021.