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

 
We decided that the Plan does not have to pay for the abdominal ultrasound (76705) provided on January 3, 
2022. 
 
You asked the Plan to pay for the ultrasound. You say that the enrollee received 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 93975 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 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 abdominal ultrasound (76705) provided on January 3, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the vision supply (V2797) and to pay more for the eyewear 
provided on February 24, 2022. 
 You asked the Plan to pay for the vision supply or pay more for the eyewear. You say that you feel you should 
not have to pay for this pair of glasses, as there has never been an issue in the past for getting these glasses 
covered. The Plan denied your request. The Plan says after the $200 allowance, your cost share for the glasses 
is $71.16. The Plan also says that you purchased a $25.00 non-covered warranty. 
 
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 they are covered by the Plan, and you have up to a $200 
allowance for covered eyewear. 
 
We looked at the file and the Plan's rules. The record shows that the full $200 allowance was applied to the 
claim for this date of service, and you purchased a $25.00 warranty, which is not covered under your plan. 
Based on this information, we decided that the Plan's rules for coverage of the vision supply or pay more for 
the eyewear have not been met. Therefore, we decided that the Plan does not have to pay for the vision supply 
(V2797) and to pay more for the eyewear provided on February 24, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 70450 billed for date of service January 23, 
2022. 
 
You asked the Plan to pay for procedure code 70450. You say that the patient had multiple exams on this date 
of service. The Plan denied your request. The Plan says payment for code 70450 is bundled into payment for 
code 70496. 
 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 procedure code 70450 billed for date of service January 23, 
2022.
Appeal type: Surgery
Decision: Favorable

 
We decided that the Plan has to pay for an unlisted nervous system procedure (64999) billed for date of service 
September 20, 2021. 
 
You asked the Plan to pay for an unlisted nervous system procedure. You say that the service at issue was a 
medical necessity for the enrollee. The Plan denied your request. The Plan says that rules for payment have not 
been met because submitted procedure code is incorrect. 
 
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and 
diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or 
payment. 
 
The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their 
decision to deny your request. Specifically, the case record does not contain support for the Plan's denial 
rationale. Support would include but is not limited to citation of relevant Medicare rules. It is the Plan's 
responsibility to substantiate its denial. In this case, the Plan's denial has not been substantiated so we must find 
in your favor. Therefore, we decided that the Plan has to pay for an unlisted nervous system procedure (64999) 
billed for date of service September 20, 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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Group 3 power wheelchair (PWC) with a power 
tilt/recline seating system. 
 
You asked the Plan to pre-approve the Group 3 PWC as requested. You say that this is a medically necessary 
replacement PWC for this enrollee. The Plan denied your request. The Plan says criteria for coverage of this 
have not been met. 
 
The Plan follows Medicare rules. Medicare rules say that Group 2 PWCs are covered for enrollees who have a 
mobility limitation that is due to a neurological condition, myopathy, or congenital skeletal deformity. 
 
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 Group 3 PWC as requested. Our 
reviewer says that the documentation does not support that the criteria for the PWC are met in this case. Our 
physician reviewer found the enrollee is a 56-year-old man with a medical history that includes chronic 
obstructive pulmonary disease (COPD), chronic hypoxic respiratory failure, tracheostomy, congestive heart 
failure, morbid obesity, severe scoliosis and kyphosis, and a stage IV sacral decubitus wound. The enrollee is 
currently in a long-term care facility.  
 
The documentation does not support that the enrollee in this case has a mobility limitation due to a neurological 
condition, myopathy, or congenital skeletal deformity. The documentation is insufficient to demonstrate that 
the enrollee's current wheelchair no longer meets his needs, and that the cannot be repaired to meet the needs.  
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 Group 3 PWC as requested have not been met. Therefore, we decided that 
the Plan does not have to pre-approve the Group 3 power wheelchair (PWC) with a power tilt/recline seating 
system.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay more for the scanning computerized ophthalmic diagnostic 
imaging (92134) and outpatient office visit (99214) provided on March 16, 2022 by an out-of-network (OON) 
provider. 
 
You asked the Plan to pay more for the scanning computerized ophthalmic diagnostic imaging and outpatient 
office visit. You say that you are being charged two copays for this date of service. You also say that you have 
seen this provider before, received the same service, and have not been charged two copays. The Plan denied 
your request. The Plan says these services were rendered by a non-participating provider, and your contractual 
obligation is a $25 copay. 
 
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. You are responsible for a $25 copayment per Medicare-covered visit when provided by an out-of-
network provider. 
 
We looked at the file and the Plan's rules. The record shows that you received these services from an OON 
provider. The only time you are only responsible for a $15 copayment is when you receive a Medicare-covered 
visit from an in-network provider. Based on this information, we decided that the Plan's rules for coverage of 
the scanning computerized ophthalmic diagnostic imaging and outpatient office visit have not been met. 
Therefore, we decided that the Plan does not have to pay more for the scanning computerized ophthalmic 
diagnostic imaging (92134) and outpatient office visit (99214) provided on March 16, 2022 by an out-of-
network (OON) provider.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 70450 billed for date of service February 16, 
2022. 
 
You asked the Plan to pay for procedure code 70450. You say that the patient had multiple exams on this date 
of service. The Plan denied your request. The Plan says payment for code 70450 is bundled into payment for 
code 70496. 
 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 procedure code 70450 billed for date of service February 16, 
2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 70450 billed for date of service February 3, 
2022. 
 You asked the Plan to pay for procedure code 70450. You say that the patient had multiple exams on this date 
of service. The Plan denied your request. The Plan says payment for code 70450 is bundled into payment for 
code 70496. 
 
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 procedure code 70450 billed for date of service February 3, 
2022.
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. 
 
You asked the Plan to pre-approve IRF care. You say that do not agree with your denial for rehab services 
because the provider offers everything you need to help with your recovery. The Plan denied your request. The 
Plan says we believe that your continued care could be better provided at an alternative level of care such as an 
outpatient or subacute rehab facility setting. 
 
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 The complexity of the patient's nursing, medical and rehabilitation needs does not 
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The patient was 
admitted for right lower extremity pain and had below the knee amputation. Medical problems are stable. There 
are no complex nursing or rehabilitation needs.  
 
The patient does not require treatment by multiple therapies, including either physical therapy or occupational 
therapy, and an intensive rehabilitation therapy program. While the patient has a need for physical and/or 
occupational therapy, there is no documentation of a need for an intensive rehabilitation program.  
 
There is not a reasonable expectation that this patient will be able to fully participate in and benefit from the 
intensive rehabilitation therapy program provided in an IRF. 
 
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 acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for psychotherapy services provided on November 18, 2021. 
 
You asked the Plan to pay for the psychotherapy services. You say that the provider provided medically 
necessary services and should be paid. The Plan denied your request. The Plan says the medical records do not 
document consultation with the patient's primary care doctor. 
 
The Plan must follow Medicare rules. Medicare rules say that for clinical psychology services, there must be 
documentation either that the patient's physician referred the patient for the psychology services, or that the 
doctor attempted to get consent from the patient in order to consult with their physician. In this case, the 
medical record provided is silent on whether or not the patient was referred for this service.  The record is also 
silent on whether or not any attempts to consult with the patient's physician were made or if the patient declined 
such consult. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the psychotherapy services have not been met. Therefore, we decided that the Plan does not have 
to pay for psychotherapy services provided on November 18, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit provided on December 8, 2021 by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for an office visit. You say that you would like to request reconsideration of the 
denied claim. The Plan denied your request. The Plan says the provider is out-of-network and authorization is 
required prior to an out-of-network visit. 
 
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 December 8, 2021 by 
an out-of-network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to issue reimbursement for the compression stockings identified with 
code A6545 that were issued on August 25, 2021 and September 21, 2021. 
 
You asked the Plan to issue reimbursement for the compression stockings. You say that you are requesting a 
reconsideration of the Plan's denial for payment. The Plan denied your request. The Plan says these items are 
not a covered benefit under your contractual policy or by Medicare for your condition. 
 
The Plan must follow Medicare rules. Medicare rules say that compression stockings described by code A6545 
are covered only when they are used to treat an open venous stasis ulcer. Medicare rules also say that 
compression bandages and gradient compression wraps are covered only when they are used as dressings over 
a qualifying wound. 
 
The record does not show that you have open venous stasis ulcers or a qualifying wound. This means that you 
do not have a medical condition for which compression stockings can be covered or paid for by Medicare. 
Therefore, we decided that the Plan does not have to issue reimbursement for the compression stockings 
identified with code A6545 that were issued on August 25, 2021 and September 21, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit provided on January 14, 2022, by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for the office visit. You say that you sent in supporting documentation for 
reconsideration of payment on the claim. The Plan denied your request. The Plan says the rendering provider is 
an OON 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 January 14, 2022, by an 
out-of-network (OON) provider.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the physical therapy (PT) services provided on April 14, 
2022 by an out-of-network (OON) provider. 
 
You asked the Plan to pay for the PT services. You say that the services should be covered. The Plan denied 
your request. The Plan says the provider in this case is out of network. The Plan also says that PT services 
received out of network are not covered. 
 
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 provider in this case is not a network provider with the Plan. The Plan did not pre-approve the item/service 
at issue. We found no exception that would require the Plan to pay for these items/services. Therefore, we 
decided that the Plan does not have to pay for the physical therapy (PT) services provided on April 14, 2022 by 
an out-of-network (OON) provider.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for computed tomographic angiography (CTA) of the chest 
(71275) provided on March 11, 2022. 
 
You asked the Plan to pay for CTA of the chest. You say that the Place of Service (POS) code billed for this 
claim is appropriate. The Plan denied your request. The Plan says the POS code billed with this claim is not 
supported in the provided records. The records received only contain the interpretation with no indication that 
the enrollee was inpatient or outpatient. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
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 find that the POS code billed on this claim is not supported in the medical record. Specifically, the medical 
records do not indicate the location where these services were provided. Based on this information, we decided 
that Medicare rules for coverage of CTA of the chest have not been met. Therefore, we decided that the Plan 
does not have to pay for computed tomographic angiography (CTA) of the chest (71275) provided on March 
11, 2022.
Appeal type: Hospice
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the subsequent nursing facility care (99309) provided on 
May 16, 2021. 
 
You asked the Plan to pay for the evaluation and management service. You say that the service is not related to 
the enrollee's hospice diagnosis. 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 subsequent nursing facility care (99309) provided on May 
16, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for deep gum and root cleaning (D4341) and a partial denture 
(D5214), provided by a participating provider on April 21, 2022. 
 
You asked the Plan to pay for deep gum and root cleaning (D4341) and a partial denture. You say that you 
would like the Plan to pay for this. The Plan denied your request. The Plan says the rendered dental services are 
not covered. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for deep gum 
and root cleaning (D4341) and a partial denture (D5214), provided by a participating provider on April 21, 
2022.