Persius/hicric huggingface dataset:
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home health services provided from February 17, 2021, 
to March 18, 2021. 
 
You asked the Plan to pay for the home health services. You say that payment should be made. The Plan 
denied your request. The Plan says the initial Request for Anticipated Payments (RAP) claim was not received 
within 5 calendar days from the start of care. 
 
The Plan must follow Medicare rules. Medicare rules say that all Home Health Agencies (HHAs) must submit 
a request for anticipated payment (RAP) within 5 calendar days after the start of care date for initial 30-day 
periods and within 5 calendar days after the from date for each subsequent 30-day period of care, which is set 
at 0 percent at the beginning of every 30-day period.  
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the home health services have not been met. Specifically, the record indicates the RAP was not submitted within 5 days of the from the start of care date, February 17, 2021. Therefore, we decided that the 
Plan does not have to pay for the home health services provided from February 17, 2021, to March 18, 2021.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a retroperitoneal ultrasound provided on 
April 21, 2021. 
 
You asked the Plan to waive the copayment for an ultrasound. You say that you should only be billed a $30 
copayment for a specialist office visit. You say you never had the imaging done. 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 $10 
copayment for in-network radiological diagnostic services, including ultrasounds.  
 
 The medical record shows you had an ultrasound on April 21, 2021. You had a retroperitoneal ultrasound 
which is a separable payable service. You have been asked to pay a $10 copayment for an ultrasound. An 
ultrasound 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 a retroperitoneal ultrasound provided on April 21, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the medical services coded 77600-59-XU provided on 
October 7, 2021. 
 
You asked the Plan to pay for the medical services. You say that you would like this claim reprocessed and 
approved for payment. The Plan denied your request. The Plan says you billed with an incorrect combination of 
modifiers. 
 
The Plan must follow Medicare rules. The rules state that providers should bill either a -59 modifier or a -XU 
modifier, but not both together. In this case, you have billed both a -59 and a -XU modifier on the same 
procedure code. 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 medical services coded 77600-
59-XU provided on October 7, 2021.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the computed tomography (CT) spine. 
 
You asked the Plan to pre-approve the CT scan. You say that this was an accident with a Plan facility due to 
staff negligence in not wiping water off the floor. This accident and subsequent CT scan are the Plan's 
responsibility to pay for and follow up. The Plan denied your request. The Plan says there is no medical 
indication for a spinal CT scan for acute low back pain without radiculopathy or prior management. It is 
appropriate to follow up with your PCP for evaluation and determination of appropriate imaging. 
 
The Plan must follow Medicare rules. Medicare rules say that CT scans are covered only when they are 
medically necessary.  
 
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 CT scan. Our reviewer says that the 
requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found in this case the record indicates that the enrollee had a fall causing acute back pain. The medical 
records provided do not indicate the presence of red flag symptoms or neurologic deficit. The provided records 
do not indicate the medical necessity or reasonableness, as defined by Medicare rules, of the requested service. 
The elements of the coverage criteria are not satisfied, and the requested service cannot be recommended. 
 
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 CT scan have not been met. Therefore, we decided that the Plan does not 
have to pre-approve the computed tomography (CT) spine.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99100 billed for date of service July 8, 2021. 
 
You asked the Plan to pay for procedure code 99100.. You say that these services were medically necessary 
and billed appropriately. The Plan denied your request. The Plan says separate payment cannot be made for this 
code. 
 
The Plan must follow Medicare rules. Medicare rules say that that payment for procedure codes with a status 
indicator of 'B' on the Medicare Physician Fee Schedule Database is always bundled into payment for other 
services.  No separate payment is ever made for these procedure codes. The code in dispute in this case (99100) 
has a status indicator of 'B' on the Medicare Physician Fee Schedule Database. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of procedure code 99100. have not been met. Therefore, we decided that the Plan does not have to 
pay for procedure code 99100 billed for date of service July 8, 2021.
Appeal type: Hospice
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ground mileage (A0425), emergency ambulance 
transportation (A0427), drug therapy supplies (A0394), and routine disposable supplies (A0398) provided on 
August 10, 2021. 
 
  You asked the Plan to pay for the ground mileage, emergency ambulance transportation, drug therapy supplies, 
and routine disposable supplies. You say that payment was retracted with no explanation. You also say that the 
transport was medically necessary, and you would like this claim to be reprocessed for payment. 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 enrollees terminal condition. 
 
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 ground mileage (A0425), emergency ambulance 
transportation (A0427), drug therapy supplies (A0394), and routine disposable supplies (A0398) provided on 
August 10, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a pneumatic compression pump from an out of network 
(OON) provider. 
 You asked the Plan to pre-approve the OON pneumatic compression pump. You say that you are the only 
provider in the enrollee's geographical area that can supply the Airos brand lymphedema pump. You say that 
the clinical documentation demonstrates that the Airos brand increases blood flow and encourages extracellular 
fluid clearance. You say that this specific device provides cycles of compressed air at certain adjustable 
pressures and then inflates and deflates garments to move fluid. You say that the Airos brand has clearing mode 
and focal mode. You say that the enrollee has tried other devices which have led to a lot of obstacles. You say 
that using an in-network lymphedema pump, the enrollee would suffer through complex complications and 
would likely result in the enrollee needing to be sent back to the hospital. The Plan denied your request. The 
Plan says a pneumatic compression pump can be obtained through an in-network provider. 
 
Medicare rules generally allow plans to restrict enrollees to using plan providers as long as there are plan 
providers available to meet the enrollees needs. The enrollees contract with the Plan says that, with few 
exceptions, enrollees must use contract providers for care.  
 
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 OON pneumatic compression 
pump. Our reviewer says that the criteria for coverage of OON care have not been met. Our physician reviewer 
found the record indicates that the enrollee has lymphedema. The records provided do not demonstrate that the 
Plan's available devices would not be effective for the enrollee's specific clinical condition or be 
contraindicated.  The Plan has shown that there are network provider's available to offer the services that the 
enrollee requires. 
 
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 OON pneumatic compression pump have not been met. Therefore, we 
decided that the Plan does not have to pre-approve a pneumatic compression pump from an out of network 
(OON) provider.
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pre-approve the skin graft (15271) and Apligraf (Q4101). 
 
You asked the Plan to pre-approve the skin graft (15271) and Apligraf (Q4101). You say that the ulcers are 
extensive covering larger areas of medial and lateral ankle malleolar regions. You say that you are asking to 
apply the Apligraf skin substitution to attempt to close the wound. The Plan denied your request. The Plan says 
that the request remains denied. 
 
The Plan must follow Medicare rules. Medicare rules say that if there are no specific coverage rules for an item 
or service, then that item or service will be covered when it is medically necessary.  
 
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 skin graft (15271) and Apligraf 
(Q4101). Our reviewer says that the documentation supports that Apligraf is medically reasonable and 
necessary in this case. Our physician reviewer found that the enrollee has chronic wounds on his right ankle. 
The enrollee has an ulcer, has a clean granular base, is clean and free of necrotic debris or exudate, and has 
adequate circulation/oxygenation to support tissue growth/wound healing. Appropriate debridement has been 
done and a comprehensive wound treatment plan has been developed. The circumstances as to why the wound 
has failed to respond to standard wound care treatment of greater than 4 weeks, references specific 
interventions that have been utilized, as well as a plan for the advanced biologic skin substitute. 
 
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 skin graft (15271) and Apligraf (Q4101) have been met. Therefore, we 
decided that the Plan has to pre-approve the skin graft (15271) and Apligraf (Q4101).  
 
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 a vehicle seat lift. 
 
You asked the Plan to pre-approve the lift. You say that this is medically necessary. The Plan denied your 
request. The Plan says this is not a covered benefit. 
 
The Plan must follow Medicare rules. The rules state that for equipment to be covered, it must be appropriate 
and needed for use inside the home.  
 
The item at issue in this appeal is for use outside of the home. Although this item may be helpful, neither 
Medicare nor the Plan covers equipment for use outside the home. Therefore, we decided that the Plan does not 
have to pre-approve a vehicle seat lift.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pay for physical therapy services (97530, 97140, 97110) provided on 
November 4, 2021, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for physical therapy services. You say that this should be covered because it was the 
enrollee's last visit. The Plan denied your request. The Plan says this was not authorized. 
 
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 physical therapy services (97530, 97140, 97110) 
provided on November 4, 2021, by an out-of-network (OON) provider.
Appeal type: Imaging
Decision: Favorable

 
We decided that the Plan has to pre-approve magnetic resonance imaging (MRI) of the cervical spine. 
 
You asked the Plan to pre-approve the MRI. You say that this is medically necessary. The Plan denied your 
request. The Plan says that there are no doctor's notes that show other tests done for this problem. 
 
The Plan must follow Medicare rules. Medicare rules say that MRIs are covered only when they are medically 
necessary.  
 
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 MRI. Our reviewer says that the 
requested MRI is medically reasonable and necessary. Our physician reviewer found you have had two prior 
neck fusion. Recently, you had a positive electromyography (EMG) with active and chronic denervation at C-7. 
You had epidural and facet steroid injections on 11/5/21, but you have increased pain. The last MRI was 
7/28/21. Since you have increased symptoms after an interventional porcedure, and a positive EMG, MRI of 
the cervical spine is reasonable and indicated. 
 
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 MRI have been met. Therefore, we decided that the Plan has to pre-approve 
magnetic resonance imaging (MRI) of the cervical spine.  
 
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: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for hearing aids provided by an out-of-network (OON) provider. 
 
You asked the Plan to pay for OON hearing aids. You say that you would like a specific pair of hearing aids to 
be covered. The Plan denied your request. The Plan says these hearing aids are not covered under your benefits. 
 
Medicare does not pay for hearing aids or related services. However, the Plan offers a hearing aid benefit that 
exceeds Medicare coverage. For that reason, the plans coverage rules apply in this case. The Plan pays for 
hearing aids only when they are provided by the Plans hearing aid vendor and are one of the hearing aid types 
listed in the Evidence of Coverage. 
 
We looked at the file, and the Plan's rules. The hearing aids requested are not one of the types covered by the 
Plan and will not be provided by a participating provider. Based on this information, we decided that the Plan's 
rules for coverage of the hearing aids have not been met. Therefore, we decided that the Plan does not have to 
pay for hearing aids provided by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the observation care discharge day management (99217) 
provided on September 17, 2021. 
 
You asked the Plan to pay for the observation care discharge day management (99217). You say that the 
medical records substantiate the billing for CPT code 99217 and support the frequency of the services rendered. 
You say that reconsideration is requested based on the attached medical records. The Plan denied your request. 
The Plan says a qualifying procedure code was not reported, paid, or otherwise identified. 
 
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 99217 is observation care discharge day management 
(This code is to be utilized to report all services provided to a patient on discharge from outpatient hospital 
"observation status" if the discharge is on other than the initial date of "observation status." To report services 
to a patient designated as "observation status" or "inpatient status" and discharged on the same date, use the 
codes for Observation or Inpatient Care Services [including Admission and Discharge Services, 99234-99236 
as appropriate.]). 
 
We find that CPT code 99217 is not supported in the medical record. Specifically, there is no evidence that an 
initial or subsequent observation service has been billed. Based on this information, we decided that Medicare 
rules for coverage of the observation care discharge day management (99217) have not been met. Therefore, 
we decided that the Plan does not have to pay for the observation care discharge day management (99217) 
provided on September 17, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services provided on October 8, 2021, by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for the lab services. You say that you disagree with the Plan's denial as you were not 
aware of the prior authorization requirement. The Plan denied your request. The Plan says unauthorized, non-
plan care is 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. 
 
Neither your organization nor the referring provider in this case is 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 lab services provided on October 8, 2021, by an out-of-network (OON) 
provider.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for laboratory services provided to the enrollee on January 28, 
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 place of service on the claim form must reflect the location of the patient when the specimen 
was obtained. 
 
The Plan must follow Medicare rules. Medicare rules say that lab services, the POS code must reflect the 
location in which the sample was taken. POS code 81 is used to describe samples taken by the laboratory 
directly. 
 We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the services have not been met. Specifically, this claim was billed with the laboratory POS code. 
The records do not support that the sample was taken in a laboratory setting. Therefore, we decided that the 
Plan does not have to pay for laboratory services provided to the enrollee on January 28, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the medical services coded 77600 provided on September 4, 
2021. 
 
You asked the Plan to pay for the medical services. You say that you would like this claim reprocessed and 
approved for payment. The Plan denied your request. The Plan says you have billed with claim with an 
incorrect combination of modifiers. 
 
The Plan must follow Medicare rules. The rules state that providers should bill either a -59 modifier or a -XU 
modifier, but not both together. In this case, you have billed both a -59 and a -XU modifier on the same 
procedure code. 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 medical services coded 77600 
provided on September 4, 2021.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Promethazine tablet for the enrollee. 
 
You asked the Plan to pre-approve the drug. You say that this is medically necessary. The Plan denied your 
request. The Plan says the plan does not include a pharmacy or drug benefit. 
 
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-
administered drugs. The self-administered drugs requested here are not among the types which are covered by 
Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve Promethazine tablet for the 
enrollee.