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

 
We decided that the Plan does not have to pay for a below knee acrylic socket (L5629) and a below knee 
suction socket (L5647) for a lower limb prosthesis. 
 
You asked the Plan to pay for the below knee acrylic socket and a below knee suction socket. You say that 
these items were medically necessary. The Plan denied your request. The Plan says these features are not 
covered for an initial prosthesis. 
 
The Plan must follow Medicare rules. Medicare rules say that when an initial below knee prosthesis (L5500) or 
a preparatory below knee prosthesis (L5510, L5520,L5530, L5540) is provided, prosthetic substitutions and/or 
additions of procedures and components are covered in accordance with the functional level assessment except 
for codes L5629, L5638, L5639, L5646, L5647, L5704, L5785, L5962, and L5980 which will be denied as not 
reasonable and necessary. 
 
We looked at the file and Medicare rules. The requested features are non-covered when added to an initial prosthesis. Based on this information, we decided that Medicare rules for coverage of the below knee acrylic 
socket and a below knee suction socket have not been met. Therefore, we decided that the Plan does not have 
to pay for a below knee acrylic socket (L5629) and a below knee suction socket (L5647) for a lower limb 
prosthesis.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an eye refraction provided on February 16, 2022. 
 
You asked the Plan to pay for an eye refraction. You say that an eye refraction is needed to determine your 
prescription and should be covered by your insurance. The Plan denied your request. The Plan says original 
Medicare doesn't cover routine eye exams (eye refractions) for eyeglasses/contacts. 
 
The Plan must follow Medicare rules. Medicare does not pay for procedures performed in the course of any eye 
exam to determine the refractive state of the eyes. Refractive procedures are not covered even when done in 
connection with otherwise covered diagnosis or treatment of illness or injury. 
 
We looked at the file and the Medicare rules. Medicare does not pay for procedures performed in the course of 
any eye exam to determine the refractive state of the eyes. Therefore, we decided that the Plan does not have to 
pay for an eye refraction provided on February 16, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for foot orthotics (L3030). 
 
You asked the Plan to pay for foot orthotics. You say that you would like the Plan to reconsider their denial. 
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 pay for foot orthotics (L3030).
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for psychotherapy services provided on February 16, 2022. 
 
You asked the Plan to pay for psychotherapy services. The Plan denied your request. The Plan says Licensed 
Professional Counselors (LPCs) are not able to be reimbursed by Medicare. 
 
The Plan must follow Medicare rules. Medicare rules say that a Licensed Professional Counselor is not eligible 
to participate in the Medicare program.  
 
We looked at the file and Medicare rules. The provider at issue in this case is a Licensed Professional 
Counselor. Medicare says that a Licensed Professional Counselor is not eligible to participate in the Medicare 
program. Therefore, we decided that the Plan does not have to pay for psychotherapy services provided on 
February 16, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an electrocardiogram, routine ECG provided on  
February 22, 2022. 
 
You asked the Plan to pay for an electrocardiogram, routine ECG. The Plan denied your request. The Plan says 
non-emergent, non-urgent services with out-of-network providers require prior authorization. 
 
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 did not pre-approve the 
service at issue. We found no exception that would require the Plan to pay for these services. Therefore, we 
decided that the Plan does not have to pay for an electrocardiogram, routine ECG provided on 
February 22, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 76000, 69990, and 29930, billed for date of 
service February 1, 2022. 
 
You asked the Plan to pay for procedure codes 76000, 69990, and 29930. The Plan denied your request. The 
Plan says these codes are bundled. 
 
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 76000 
is a column II code to column I code 22162. We have also confirmed that code 69990 is a column II code to 
column I code 22162. 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. 
 
We also find that CPT code 29930 has a status indicator of B on the Physician Fee Schedule. This means that 
CPT code 29930 is not separately payable. Based on this information, we decided that Medicare rules for 
coverage of procedure code 29930 have not been met. Therefore, we decided that the Plan does not have to pay 
for procedure codes 76000, 69990, and 29930, billed for date of service February 1, 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 the requested admission to an IRF is medically 
necessary. The Plan denied your request. The Plan says the requested admission to an IRF does not meet 
criteria. 
 
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 enrollees medical conditions are stable on outpatient medications with no issues 
that require a physicians evaluation three or more times per week. The enrollee does require physical therapy 
and occupational therapy services, but the medical records provided do not clarify why she requires an 
intensive inpatient rehabilitation therapy program. Provided records do not explain why the intensive inpatient 
rehabilitation therapy program is necessary and why therapy at a lower level of care such as in a skilled nursing 
facility is not appropriate for the enrollee. 
 
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: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services. 
 
You asked the Plan to pre-approve the LTACH services. You say that the requested admission to a LTACH is 
medically necessary. The Plan denied your request. The Plan says the requested admission to a LTACH does 
not meet criteria. 
 
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically 
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 
 
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 LTACH services. Our reviewer says 
that the requested LTACH care is not considered medically reasonable and necessary in this case. Our 
physician reviewer found you are improving but still require acute care services before transitioning to a lower 
level of care. You continue to receive acute care services, and these have not been denied. The medical record 
does not indicate that you require services that she is not currently receiving but that would be available at the 
LTACH facility. 
 
 
 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 LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve long term acute care hospital (LTACH) services.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the inpatient hospital care provided from 
February 27, 2022, through March 5, 2022. 
 
You asked the Plan to waive the copayment. You say that you are requesting a reconsideration of the Plan's 
denial for payment. The Plan denied your request. The Plan says the copayment has been applied correctly to 
the services provided. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). The enrollees contract with the Plan clearly says that enrollees 
must pay a $355 copayment per day, for days 1 to 4 and a $0 copayment per day, for days 5 to 90, for inpatient 
hospital care.  
 
 The enrollee has been asked to pay $1,420 ($355 copayment x 4 days) for the inpatient hospital care provided. 
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 care provided from 
February 27, 2022, through March 5, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a medical eye exam (92004) to be provided by an out-
of-network (OON) provider. 
 
You asked the Plan to pre-approve a medical eye exam. You say that your eyes are always dry, and you would 
like to see the requested provider. The Plan denied your request. The Plan says there are several in-network 
providers available that can provide the service at issue. The Plan also says the Plan only provides coverage for 
vision services when they are performed by a participating vision provider. 
 
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 pre-approve care from out-of-network providers only in cases involving 
emergencies, out of area urgent care and care that cannot be provided by network providers. 
 
The requested provider in this case is not a network provider with the Plan. The Plan has network providers 
available who can provide the items/services at issue in this appeal. We found no exception that would require 
the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve 
a medical eye exam (92004) to be provided by an out-of-network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services rendered on February 17, 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 separately payable. 
 
The Plan must follow Medicare rules. The rules say that all ESRD-related laboratory services are included in 
the ESRD PPS base rate and must be reported by the ESRD facility and are not separately paid. 
 
We looked at the file and Medicare rules. The file shows that the laboratory services were rendered for end-
stage renal disease (ESRD). Payment is included in the payment to the ESRD facility. Therefore, we decided 
that the Plan does not have to pay for the laboratory services rendered on February 17, 2022.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve continued skilled nursing facility (SNF) care. 
 
You asked the Plan to pre-approve continued SNF care. You say that the requested continued SNF care is 
medically necessary. The Plan denied your request. The Plan says the requested continued SNF care does not 
meet criteria. 
 The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors 
listed in the Medicare rules section are met. Custodial care is not covered. 
 
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 continued SNF care. Our reviewer says 
that the service is not medically necessary. Our physician reviewer found you do not have documented skilled 
nursing needs or documented skilled therapy needs. Daily skilled services are not required to establish a 
maintenance program or to prevent deterioration of your condition. Your care needs are custodial and can, as a 
practical matter, be provided at a lower level of care. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of continued SNF care have not been met. Therefore, we decided that the Plan 
does not have to pre-approve continued skilled nursing facility (SNF) care.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the sterile gloves rendered on February 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 are not covered. 
 
The Plan must follow Medicare rules. The rules say that sterile gloves are not covered because they are 
hygienic items that are non-reusable. 
 
We looked at the file and Medicare rules. The services at issue are sterile gloves. These services are not 
covered by Medicare. Therefore, we decided that the Plan does not have to pay for the sterile gloves rendered 
on February 12, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an ultrasound (76700) provided on December 21, 2021. 
 
You asked the Plan to pay for an ultrasound. You say that this is separately payable. The Plan denied your 
request. The Plan says this is supported in the records. 
 
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 76700 is ultrasound, abdominal, real time with image 
documentation; complete. 
 
 
 
 
 
 
 
 We find that CPT code 76700 is not supported in the medical record. Specifically, the submitted records do not 
include image documentation. Based on this information, we decided that Medicare rules for coverage of an 
ultrasound have not been met. Therefore, we decided that the Plan does not have to pay for an ultrasound 
(76700) provided on December 21, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services rendered on August 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 the services were not billed correctly. 
 
The Plan must follow Medicare rules. The rules say that laboratory shall not report multiple individual CPT 
codes describing the component test results.  
 
We looked at the file and Medicare rules. The file shows that the testing at issue has component test results and 
was not billed as one test under code 81479. Therefore, we decided that the Plan does not have to pay for the 
laboratory services rendered on August 8, 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 December 17, 2021. 
 
You asked the Plan to pay for the ambulance service. You say that you fainted due to a vertigo attack. You say 
that the paramedics gave you medication. You also say that you would like this bill to be paid. The Plan denied 
your request. The Plan says since there was no 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 December 17, 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 December 17, 2021.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for ambulance transportation services (A0428, 
A0425) provided on January 21, 2022. 
 
You asked the Plan to waive the copayment for the ambulance transportation services. You say that the 
services should be covered as you disagree with the charges. The Plan denied your request. The Plan says the 
cost-sharing applied correctly based on the services provided. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $270 
copayment for Ambulance services.  
 
 
  You have been asked to pay a $268.67 copayment for the ambulance transportation services. 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 ambulance transportation services (A0428, A0425) provided on 
January 21, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the office emergency care (99058) provided on November 9, 
2021. 
 You asked the Plan to pay for code 99058. You say that you would like the Plan to reconsider their denial of 
payment. The Plan denied your request. The Plan says the services are not covered as billed. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
We find that CPT code 99058 has a status indicator of B on the Physician Fee Schedule. This means that CPT 
code 99058 is not separately payable. Based on this information, we decided that Medicare rules for coverage 
of code 99058 have not been met. Therefore, we decided that the Plan does not have to pay for the office 
emergency care (99058) provided on November 9, 2021.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for outpatient services (G0463) provided on November 25, 2021 
to December 24, 2021 in India. 
 
You asked the Plan to pay for the outpatient services. You say that this service was medically necessary. The 
Plan denied your request. The Plan says the service was non-emergent and is not covered. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that enrollees have world-wide coverage only for emergency services. Non-emergency and routine 
services received outside the United States are not covered 
 
The service at issue is not emergency care and was provided outside the United States. This service is not 
covered by Medicare or the plan. Therefore, we decided that the Plan does not have to pay for outpatient 
services (G0463) provided on November 25, 2021 to December 24, 2021 in India.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services (81206, 81235, 81321) provided October 6, 
2021. 
 
You asked the Plan to pay for the lab services. You say that this service was medically necessary. The Plan 
denied your request. The Plan says the claim cannot be paid as billed. 
 
The Plan must follow Medicare rules. Medicare rules say that a panel constitutes a single procedural service, so 
one code must be submitted for the panel. 
 
We looked at the file and Medicare rules. Multiple unbundled codes were submitted for a single panel. Based 
on this information, we decided that Medicare rules for coverage of the lab services have not been met. 
Therefore, we decided that the Plan does not have to pay for lab services (81206, 81235, 81321) provided 
October 6, 2021.
Appeal type: Surgery
Decision: Favorable

 
We decided that the Plan has to pay for the surgical services rendered on December 29, 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 that procedure code 27357 is inclusive to code 27447 and not separately payable. 
 
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. The Plan states that procedure code 27357 is inclusive to code 27447 and cannot 
be paid separately; however, there are not active National Correct Coding Initiative (NCCI) procedure-to-
procedure edits for this code pair. The Plan has not provided any documentation to support that code 27357 is 
not payable as billed. Therefore, we decided that the Plan has to pay for the surgical services rendered on 
December 29, 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.