Persius/hicric huggingface dataset:
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the transcutaneous electrical nerve stimulator (TENS) unit 
and related supplies billed for date of service June 13, 2022. 
 
You asked the Plan to pay for the TENS unit and supplies. You say that these items were medically necessary 
and ordered by the patient's doctor. The Plan denied your request. The Plan says no valid proof of delivery was 
provided. 
 
The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when there are both a 
physician order and proof of delivery.  
 
The record does not contain a valid proof of delivery. Specifically, you provided a packing slip that was dated May 13, 2022, and a delivery ticket that was dated May 16, 2022.  There is no delivery information supporting 
the date of service that you actually billed (June 13, 2022). Therefore, we decided that the Plan does not have to 
pay for the transcutaneous electrical nerve stimulator (TENS) unit and related supplies billed for date of service 
June 13, 2022.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the paramedic intercept (pi), rural area, transport furnished 
by a volunteer ambulance company which is prohibited by state law from billing third party payers (A0432) 
provided on July 1, 2021. 
 
You asked the Plan to pay for the paramedic intercept. You say that you dont feel you should be responsible 
for this bill. The Plan denied your request. The Plan says this service is not covered. 
 The rules say that Medicare pays for advanced life support (ALS), in accordance with state and local laws by 
an emergency medical technician (EMT) intermediate or EMT-Paramedic only in certain circumstances. 
Medicare allows ALS paramedic intercept services only when the services are furnished in a rural area as 
defined above. It is noted that the only State in which these criteria are met is New York. 
 
The paramedic intercept services at issue in this appeal were not furnished in an area that is considered rural 
according to the Medicare definition. Therefore, we decided that the Plan does not have to pay for the 
paramedic intercept (pi), rural area, transport furnished by a volunteer ambulance company which is prohibited 
by state law from billing third party payers (A0432) provided on July 1, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for code 99220-GQ billed for date of service June 8, 2022. 
 
You asked the Plan to pay for code 99220-GQ. You say that you believe this modifier was billed correctly. The 
Plan denied your request. The Plan says the GQ modifier was billed inappropriately for this service. 
 
The Plan must follow Medicare rules. Medicare rules say that se of the GQ modifier means that the provider is 
certifying that they collected and sent the asynchronous medical file at the distant site from a federal 
telemedicine demonstration project conducted in Alaska or Hawaii. There is no evidence that the service in 
question was part of a demonstration project in Alaska or Hawaii, so a different modifier should have been 
used. Therefore, we decided that the Plan does not have to pay for code 99220-GQ billed for date of service 
June 8, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the deductible for office visit provided on June 10, 2022. 
 
You asked the Plan to waive the deductible for office visit. You say that you should not have been billed an 
additional charge. You would like the Plan to pay for this bill. The Plan denied your request. The Plan says this 
cost sharing was charged correctly. 
 
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 $150 
deductible for Physician/Practitioner services, including doctors office visits. 
 
You have been asked to pay a $150 deductible for office visit. This item/service falls within the 
Physician/Practitioner services, including doctors office visits 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 deductible for office visit provided on June 10, 2022.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home health services rendered from December 16, 2021, 
to January 12, 2022. 
 
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. The rules say that a RAP and a claim must be submitted for all episodes 
for which Medicare makes payment based on HIPPS codes. 
 
We looked at the file and Medicare rules. The file shows that the RAP was not submitted within five calendar 
days from the start of care. Therefore, we decided that the Plan does not have to pay for the home health 
services rendered from December 16, 2021, to January 12, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for laboratory services provided on June 06, 
2022. 
 
You asked the Plan to waive the copayment for laboratory services. You say that you have not been charged a 
copayment in the past, therefore you should not have to pay this. The Plan denied your request. The Plan says 
this cost sharing was charged correctly. 
 
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 $10 
copayment for outpatient diagnostic tests and therapeutic services and supplies. 
 
You have been asked to pay a $10 copayment for laboratory services. This item/service falls 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 laboratory services provided on June 06, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to reduce the copayment for an office visit (99214) provided on April 
8, 2022. 
 
You asked the Plan to reduce the copayment for an office visit. You say that this visit should be billed the same 
way as your primary care physician (PCP) since the provider's medical license is the same. You asked the Plan 
to reduce the copayment from $40 to $10. The Plan denied your request. The Plan says this cost sharing was 
charged correctly. The provider is not a PCP and is not associated with your PCP. You presented to a walk-in 
clinic to receive care from a specialist.  
 
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 $40 
copayment for each covered visit or consultation in an outpatient location with a specialist.  
 
You have been asked to pay a $40 copayment for an office visit. This service falls within the 
physician/practitioner services, including doctors office visits 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 reduce the copayment for an office visit (99214) provided on April 8, 
2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve foot orthotics (L3020). 
 
You asked the Plan to pre-approve these items. You say that you are requesting a reconsideration of the Plan's 
denial. The Plan denied your request. The Plan says these items are not a covered benefit by the Plan or by 
Medicare for your condition. 
 
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 (L3020).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve additional mileage. 
 
You asked the Plan to pre-approve the additional mileage. You say that you have been seeing this doctor for 
two years and need to see this doctor every six months for your right wrist. The Plan denied your request. The 
Plan says the additional mileage is not a covered benefit. 
 
Medicare does not cover transport in a vehicle that is not an ambulance. However, the Plan offers a 
transportation benefit that exceeds Medicare coverage. For that reason, the Plans coverage rules apply in this 
case. The Plan covers a maximum of 50 miles of driving distance trips per year.  
 
 We looked at your request, the records in the case file, and the rules. Based on this information, we decided 
that you have exhausted the Plan maximum benefit for coverage of routine transportation. Therefore, we 
decided that the Plan does not have to pre-approve additional mileage.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an outpatient surgery provided on May 9, 
2022. 
 
You asked the Plan to waive the copayment for an outpatient surgery. You say that you believe it is too much 
for him to pay. The Plan denied your request. The Plan says this cost sharing was charged correctly. 
 
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 $350 
copayment for outpatient surgery.  
 
You have been asked to pay a $350 copayment for an outpatient surgery. This item/service falls within the 
outpatient surgery 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 outpatient surgery 
provided on May 9, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for at home oxygen equipment provided on 
June 30, 2022. 
 
You asked the Plan to waive the coinsurance for at home oxygen equipment. You say that you would like this 
waived as you are getting hit with a lot of copayments at once. The Plan denied your request. The Plan says this 
cost sharing was charged correctly. 
 
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 10% 
coinsurance for durable medical equipment (DME) and related supplies. The allowed amount of this drug or 
item is $1055.23, resulting in a coinsurance amount of $105.52 ($1055.23 x 10% = $105.52). 
The allowed amount of this drug or item is $47, resulting in a coinsurance amount of $4.70 ($47 x 10% = 
$4.70).  
The allowed amount of this drug or item is $135, resulting in a coinsurance amount of $13.50 ($135 x 10% = 
$13.50). 
$105.52 + $4.70 + $13.50 = a $123.72 total. You have been asked to pay a total $123.72 coinsurance for at home oxygen equipment. This item/service falls 
within the durable medical equipment (DME) and related 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 coinsurance for at home oxygen equipment provided on June 30, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services rendered on November 8, 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 this claim is a duplicate of a previously paid claim and was correctly denied. 
 
The Plan must follow Medicare rules. The rules say that claims or claim lines that have been determined to be 
exact duplicates of another claim or claim line are denied. However, such denials may be appealed. 
 
We looked at the file and Medicare rules. The file includes evidence that the items/services at issue were 
reimbursed by the Plan on January 27, 2022, and January 28, 2022. Comparison of the two claims shows these 
are exact duplicates. There is no evidence presented to support that the billed items/services were provided 
twice on the same date. Based on this information, we decided that the Medicare rules for these services have 
not been met. Therefore, we decided that the Plan does not have to pay for the laboratory services rendered on 
November 8, 2021.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Percutaneous Image-Guided Lumbar Decompression 
procedure (0275T). 
 
You asked the Plan to pre-approve the procedure. You say that this procedure is medically necessary. The Plan 
denied your request. The Plan says coverage rules have not been met. 
 
The Plan must follow Medicare rules. Medicare rules say that Percutaneous Image-Guided Lumbar 
Decompression (PILD) is covered by Medicare when provided in an approved clinical study. 
 
We looked at the file and Medicare rules. Records do not show that the enrollee is part of an approved clinical 
study. Based on this information, we decided that Medicare rules for coverage of the procedure have not been 
met. Therefore, we decided that the Plan does not have to pre-approve a Percutaneous Image-Guided Lumbar 
Decompression procedure (0275T).
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to pay for outpatient hospital services billed with codes 93610, 90471, 
and 90715, for date of service July 7, 2022. 
 
You asked the Plan to pay for codes 93610, 90471, and 90715. You say that these codes are covered and were 
medically necessary. The Plan denied your request. The Plan says no separate payment is made for these codes. 
 The Plan must follow Medicare rules. Medicare rules say that for STV-packaged codes (i.e., those with a status 
indicator of Q1), no separate payment is made for these codes if billed with a code with an S, T, or V status 
indicator.  In addition, codes with a status indicator of N are never separately paid.   
 
In this case, codes 73610 and 90471 have a status indicator of Q1, meaning they are considered STV-packaged 
codes. In addition to these codes, code 99283 was billed on the same claim.  Code 99283 has a status indicator 
of V.  This means that codes 73610 and 90471 are not separately payable. Also, code 90715 has a status 
indicator of N, meaning that it is never separately paid.  
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of codes 93610, 90471, and 90715 have not been met. Therefore, we decided that the Plan does not 
have to pay for outpatient hospital services billed with codes 93610, 90471, and 90715, for date of service July 
7, 2022.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the freestanding emergency room (ER) services rendered on 
June 18, 2022. 
 
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 are not covered. 
 
The Plan must follow Medicare rules. The rules say that Medicare covers services in freestanding emergency 
departments only if the emergency clinic is affiliated with a hospital. 
 
We looked at the file and Medicare rules. The provider is a freestanding ER not affiliated with a hospital. These 
services are not covered by Medicare. Therefore, we decided that the Plan does not have to pay for the 
freestanding emergency room (ER) services rendered on June 18, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for acupuncture services you received from June 2, 2022, to July 
21, 2022. 
 
You asked the Plan to pay for the acupuncture services. You say that you are aware of the 20-visit limit, but 
you have severe pain and need to see this doctor. The Plan denied your request. The Plan says you have 
exhausted your acupuncture benefit for the year. 
 
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.   
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, you have already received 20 covered acupuncture 
visits for the year.  Additional acupuncture visits are not covered, regardless of the necessity or appropriateness 
of the service. Therefore, we decided that the Plan does not have to pay for acupuncture services you received 
from June 2, 2022, to July 21, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayments for outpatient rehab services and outpatient 
surgery services provided on August 25, 2021. 
 
You asked the Plan to waive the copayments for outpatient rehab services and an outpatient surgery services. 
You say that you don't agree with the copayments. The Plan denied your request. The Plan says the cost sharing 
will be applied according to the Plan contract. 
 
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 $20 
copayment for outpatient rehabilitation services and a $350 copayment and outpatient surgery/outpatient 
hospital facility.  
 
You have been asked to pay a $20 copayment for outpatient rehab services and a $350 copayment for an 
outpatient surgery services. The total amount you are being asked to pay is $370 ($350 + $20 = $370). 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 copayments for outpatient rehab services and outpatient surgery services 
provided on August 25, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a group 3 power wheelchair with accessories. 
 
You asked the Plan to pre-approve the group 3 power wheelchair with accessories. You say that this wheelchair 
and related accessories are medically necessary. The Plan denied your request. The Plan says the enrollee does 
not meet coverage criteria for a group 3 power wheelchair. 
 
The Plan must follow Medicare rules. The rules say that a Group 3 power wheelchair can be covered only for 
enrollees who have a mobility limitation that is due to: 
 
1. A neurological condition; 
2. Myopathy; or 
3. Congenital skeletal deformity. 
 
The file does not show that the enrollee has a mobility limitation that is due to a neurological condition, 
myopathy or congenital skeletal deformity. Since coverage criteria has not been met for the wheelchair base, 
the requested accessories are also non-covered. Therefore, we decided that the Plan does not have to pre-
approve a group 3 power wheelchair with accessories.
Appeal type: Hospice
Decision: Unfavorable

 
We decided that the Plan does not have to pay for subsequent nursing facility care provided on March 2, 2022. 
 
You asked the Plan to pay for subsequent nursing facility care. The Plan denied your request. The Plan says the 
member was enrolled in hospice on this date of service, therefore Traditional Medicare is the primary payer. 
 
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 subsequent nursing facility care provided on March 2, 2022.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for home health services provided from May 25, 2022, to June 
23, 2022. 
 
You asked the Plan to pay for home health services. You say that an NOA was submitted. The Plan denied 
your request. The Plan says the submitted NOA did not have the correct admission date. 
 
The Plan must follow Medicare rules. Medicare rules say that for all beneficiaries receiving home health 
services in 2021 whose services will continue in 2022, the home health agency (HHA) shall submit a Notice of 
Admission (NOA) with a one-time, artificial 'admission' date corresponding to the "From" date of the first 
period of continuing care in 2022.  
 We looked at the file and Medicare rules. The record shows that the submitted NOA did not have an admission 
date corresponding to the "From" date of the first period of continuing care in 2022. Based on this information, 
we decided that Medicare rules for coverage of home health services have not been met. Therefore, we decided 
that the Plan does not have to pay for home health services provided from May 25, 2022, to June 23, 2022.