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

We decided that the Plan does not have to pay for the services provided by an out-of-network provider on June 22, 2021.
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the services were not approved in advance.
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 services at issue in this appeal. The Plan did not pre-approve the services 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 the services provided by an out-of-network provider on June 22, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for observation care discharge day management (99217) 
provided April 10, 2021. 
 
You asked the Plan to pay for discharge day management services. You say that physician charged denied as a 
duplicate. This physician charge is not a duplicate. Please see both physician notes for reprocessing. The Plan 
denied your request. The Plan says the information submitted does not support the services 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. 
 
In this case, the CPT Code Manual definition of code 99217 is observation care discharge day management. 
 
We find that CPT code 99217 is not supported in the medical record. Specifically, a qualifying initial or 
subsequent observation care service was not found in the enrollee's claims history. 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. Based on this information, we decided that 
Medicare rules for coverage of discharge day management services have not been met. Therefore, we decided 
that the Plan does not have to pay for observation care discharge day management (99217) provided April 10, 
2021.
Appeal type: Practitioner Services
Decision: Favorable

We decided that the Plan has to pay for the removal of an implant (20680) provided on December 1, 2020. 
 
You asked the Plan to pay for the removal of an implant. You say that you would like reconsideration because 
the implant was removed from a different location than the primary procedure. The Plan denied your request. 
The Plan says that this procedure is considered inclusive to CPT code 28725. 
 
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 20680 is supported in the medical record. Specifically, an NCCI edit does not exist 
between CPT codes 20680 and 28725. Additionally, the record does not support that CPT code 20860 was 
integral to the primary procedure. The documentation submitted indicates that CPT code 20860 can be reported 
separately. Based on this information, we decided that Medicare rules for coverage of the removal of an 
implant have been met. Therefore, we decided that the Plan has to pay for the removal of an implant (20680) 
provided on December 1, 2020.  
 
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: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the domiciliary, rest home visit (99336) provided on May 11, 2021 by an out-of-network (OON) provider.
You asked the Plan to pay for the domiciliary, rest home visit. You say that kindly review and reprocess the claims and reimburse the doctor for services rendered in good faith and best interest to the enrollee. The Plan denied your request. The Plan says enrollee's must receive their medical services from an in-network provider with the exception being urgent or emergent services. Non-emergent services with non-contracted providers require prior authorization before services being rendered.
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 the domiciliary, rest home visit (99336) provided on May 11, 2021 by an out-of-network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the additional intraoral periapical x-ray (D0230) provided on 
July 22, 2021. 
 
You asked the Plan to pay for the additional intraoral periapical x-ray. You say that you would like this service 
to be covered. The Plan denied your request. The Plan says this service exceeds the benefit allowance. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plan's coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, you are limited to two of either codes 
D0220, D0230, D0270, D0272, D0273, or D0274 per 1 calendar year.  
The record shows that you received a first intraoral periapical x-ray (D0220) and bitewing x-ray (D0270) on 
July 22, 2021 and your additional intraoral periapical x-ray (D0230) benefit has been exhausted. Therefore, we 
decided that the Plan does not have to pay for the additional intraoral periapical x-ray (D0230) provided on 
July 22, 2021.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the electrocardiogram (EKG) rendered on
June 9, 2021.
You asked the Plan to waive the copayment for these services. You say that you disagree with the copayment.
The Plan denied your request. The Plan says the copayment was applied 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 $20
copayment for Medicare-covered non-radiological diagnostic services.
Review of the file shows that you received an EKG on June 9, 2021. You have been asked to pay a $20
copayment for these services. These services fall within the Medicare-covered non-radiological diagnostic
services 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 the electrocardiogram
(EKG) rendered on June 9, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for a domiciliary or rest home visit (99336) provided on May 19, 
2021, by an OON provider. 
 
You asked the Plan to pay for a domiciliary or rest home visit. You say that it should have been the facility's 
responsibility to obtain authorization. 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 must 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 a domiciliary or rest home visit (99336) provided 
on May 19, 2021, by an OON provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an office visit with a podiatrist (99212) rendered on July 15, 2021.
You asked the Plan to waive the copayment for an office visit with a podiatrist. You say that you have never had to pay a copayment for this service before. You also say you spoke with the Plan and were told you did not have to pay a copayment because you are diabetic. The Plan denied your request. The Plan says you were charged the correct copayment 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 $15 copayment for Podiatry Services.
You have been asked to pay a $15 copayment for an office visit (99212) with a podiatrist. The EOC is clear that there is a $15 copayment for an office visit with a Podiatrist. 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 office visit with a podiatrist (99212) rendered on July 15, 2021.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan does not have to pay for psychotherapy services (90832) provided on April 21, 2021.
You asked the Plan to pay for psychotherapy services. You say that the services at issue were a medical necessity for the enrollee. The Plan denied your request. The Plan says rules for payment have not been met.
The Plan must follow Medicare rules. Medicare rules say that the CP will attempt to consult with the enrollee's attending or primary care physician.
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of psychotherapy services have not been met. Specifically, the provided records do not document an attempt to consult with, nor a referral from, the enrollee's attending or primary care physician. Therefore, we decided that the Plan does not have to pay for psychotherapy services (90832) provided on April 21, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for an Apple Watch provided on June 16, 2021.
You asked the Plan to pay for an Apple Watch. You say that you were informed by a representative of the Plan that the Plan would provide coverage for the item at issue. The Plan denied your request. The Plan says rules for payment have not been met.
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a medical purpose. The item at issue in this appeal does not serve a purpose that is primarily medical in nature. This item is available to the general public and would be helpful even to those who are not sick or injured. Therefore, we decided that the Plan does not have to pay for an Apple Watch provided on June 16, 2021.
Your complaint about receiving erroneous or incomplete information from a representative of the Plan about your durable medical equipment benefit is not a valid appeal for medical coverage. This part of your complaint is a grievance that must be answered by the Plan. Medicare does not permit us to make a decision about these types of complaints.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the deductible for a closed treatment of carpal scaphoid 
fracture (25622) provided on May 3, 2021. 
 
You asked the Plan to waive the deductible for a closed treatment of fracture. You say that the provider did 
absolutely nothing for you. The Plan denied your request. The Plan says the correct cost-sharing was applied. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information. Your 
contract with the Plan says that there is a $750 deductible which applies to each outpatient surgery and/or 
services at an ambulatory surgical center or outpatient hospital facility.  
 
The item or service you asked the Plan to waive the deductible for falls within the "Outpatient surgery, 
including services provided at hospital outpatient facilities and ambulatory surgical centers" benefit category. 
The Plan has followed Medicare rules by clearly disclosing in the contract that there is a $750 deductible which 
applies to each outpatient surgery and/or services at an ambulatory surgical center or outpatient hospital 
facility. This cost sharing is a contractual obligation that had not been met at the time a closed treatment of 
fracture was received on May 3, 2021. Therefore, we decided that the Plan does not have to waive the 
deductible for a closed treatment of carpal scaphoid fracture (25622) provided on May 3, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the services provided by an out-of-network provider on April 
7, 2021. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the services are 
available in-network. 
 
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 services at issue in this appeal. The Plan did not pre-approve the 
services 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 the services provided by an out-of-network provider on April 7, 
2021.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pay for physical therapy services provided by a physical therapy 
assistant on February 23, 2021. 
  
You asked the Plan to pay for the physical therapy services. You say that plans are required to pay non-
contracted providers at the preferred provider rate when services are not available in the service area. You say 
that the in-network benefits should be honored, and the claim processed for payment. The Plan denied your 
request. The Plan says there is a more appropriate code for the billed service. 
 
The Plan must follow Medicare rules. Medicare rules say that the services of a physical therapy assistant (PTA) 
shall not be billed as services incident to a physician/non-physician practitioner's (NPP) service, because they 
do not meet the qualifications of a therapist.  
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the physical therapy services have not been met. Specifically, the billing provider is a nurse 
practitioner, and not a licensed therapist. As such, PTA services cannot be paid incident to this provider's 
professional services. Therefore, we decided that the Plan does not have to pay for physical therapy services 
provided by a physical therapy assistant on February 23, 2021.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pay for the monitoring services rendered on June 10, 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 procedure code 95940 is not supported.
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 95940 is continuous intraoperative neurophysiology monitoring in the operating room, one on one monitoring requiring personal attendance, each 15 minutes (List separately in addition to code for primary procedure). We find that CPT code 95940 is not supported in the medical record. Specifically, this is an add-on code that was not billed with a required primary 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 monitoring services rendered on June 10, 2021.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve removal of breast implants. 
 
You asked the Plan to pre-approve plastic surgery services. You say that over the course of time your implants 
have shifted quite a bit and you want to have them removed. The Plan denied your request. The Plan says the 
denial of authorization for this service is correct, because this request is not reconstructive in nature and does 
not meet the coverage criteria. 
 
The Plan follows Medicare rules. Medicare rules state that certain reconstructive surgery procedures are 
covered, but cosmetic surgery 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 plastic surgery services. Our reviewer 
says that you do not meet the Medicare criteria for the requested plastic surgery services. Our physician 
reviewer found the record indicates that you had breast reconstruction after mastectomies for breast cancer. 
You have a soft grade 1 Bakers capsule. The requested procedure would be performed for cosmetic purposes. 
The medical record does not establish the medical necessity and reasonableness of the requested procedure. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of plastic surgery services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve removal of breast implants.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the services provided by an out-of-network provider on May 6, 2021.
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the services were not approved in advance.
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 services at issue in this appeal. The Plan did not pre-approve the services 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 the services provided by an out-of-network provider on May 6, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve additional power wheelchair accessories (E2300, 
E2311, E2313, E2377) for the enrollee. 
 
You asked the Plan to pre-approve the additional accessories. You say that this is medically necessary. The 
Plan denied your request. The Plan says this is not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are 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 the additional accessories. Our reviewer 
says that the requested additional accessories are not considered medically reasonable and necessary in this 
case. Our physician reviewer found the documentation does not reveal that the enrollee requires other types of 
proportional input devices (e.g., mini-proportional or compact joysticks, touchpads, chin control, head control, 
etc) or non-proportional input devices (e.g., sip and puff, head array, etc). The enrollee does not need to operate 
3 or more powered seating actuators through the drive control, a separate display (i.e., for alternate control 
devices), other electronic devices (e.g., control of an augmentative speech device or computer through the 
chair's drive control), or an attendant control. The enrollee's function in the upper extremities with the ability to 
feed himself supports that the patient can control any power options through their own individual switches. 
 
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 additional accessories have not been met. Therefore, we decided that the 
Plan does not have to pre-approve additional power wheelchair accessories (E2300, E2311, E2313, E2377) for 
the enrollee.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for the automatic defibrillator rentals (K0606) 
provided from April 16, 2021, through June 16, 2021. 
 
You asked the Plan to waive the coinsurance. You say that you are requesting a reconsideration of the Plan's 
denial for payment. The Plan denied your request. The Plan says the coinsurance has been applied correctly to 
the items 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 20% 
coinsurance for Medicare-covered durable medical equipment and related supplies.  
 
You have been asked to pay $1,622.97 which includes the (Plan allowed amount of $2,704.94 x 20% 
coinsurance=$540.99 x 3 days) for the durable medical equipment provided.  
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 the automatic defibrillator rentals (K0606) 
provided from April 16, 2021, through June 16, 2021.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for the x-ray services coded 71045 provided on July 4, 2021. 
 
You asked the Plan to pay for the x-ray services. You say that you would like the plan to reconsider their 
denial. The Plan denied your request. The Plan says the services billed are not separately payable. 
 
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 71045 
for the x-ray services is a column II code to column I code 36573. 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 x-ray services coded 71045 provided on 
July 4, 2021