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

 
We decided that the Plan does not have to pay for a wound care visit provided on January 25, 2023. 
 
You asked the Plan to pay for a wound care visit. You say that your Plan has always taken care of the 
paperwork in the past and you should not have to take care of prior authorization. The Plan denied your 
request. The Plan says that unauthorized, out-of-network 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. 
 
The provider of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. The Plan 
did not pre-approve the item(s)/service(s) at issue. We found no exception that would require the Plan to pay 
for the item(s)/service(s). Therefore, we decided that the Plan does not have to pay for a wound care visit 
provided on January 25, 2023.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an additional unit of procedure code 77012 rendered on 
February 24, 2023. 
 
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 CPT 77012 can only allow for one unit, regardless of number of needle placements. 
 
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 77012 is "Computed tomography guidance for needle 
placement (eg, biopsy, aspiration, injection, localization device), radiological supervision and interpretation." 
 
We asked our coder to carefully review the case file and apply the relevant Medicare rules to determine if the 
Plan was correct in denying the request to pay for the services. Our reviewer says that the services at issue in this case were not supported by the medical records. Our reviewer found that CPT codes 76942, 77002, 77003, 
77012, and 77021 describe radiologic guidance for needle placement by different modalities. Medicare 
payment policy allows one unit of service for any of these codes at a single patient encounter regardless of the 
number of needle placements performed. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the services have not been met. Therefore, we decided that the Plan does not 
have to pay for an additional unit of procedure code 77012 rendered on February 24, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for podiatry services provided on December 12, 2022. 
 
You asked the Plan to pay for the podiatry services. You say that you are not a diabetic and you have had this 
procedure done in the past and it was covered. The Plan denied your request. The Plan says paring or cutting of 
benign hyperkeratotic lesion (e.g., corn or callus) is only covered for Medicare members with a diabetic 
diagnosis. 
 
The Plan must follow Medicare rules. The rules say that routine foot care is not covered. The only exception is 
for those who have a condition that results in severe loss of circulation or areas of poor sensation in the legs or 
feet or have fungal nails.  
 
Records do not show that any of these conditions are present. The services you are asking the Plan to pay for 
are routine foot care services. Based on this information, we decided that Medicare rules for coverage of the 
podiatry services have not been met. Therefore, we decided that the Plan does not have to pay for podiatry 
services provided on December 12, 2022.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for psychotherapy services provided on December 27, 2022. 
 
You asked the Plan to pay for psychotherapy. You say that the services were medically necessary. The Plan 
denied your request. The Plan says the provider must attempt to consult the attending or primary care physician 
about the services furnished and document the consent or declination date to consultations, and the date of consultations in the patients medical record. There was no documentation of contact in the patient record. The 
signature of an attending provider does not satisfy the documentation criteria. 
 
The Plan must follow Medicare rules. Medicare rules say that the CP or LCSW must document, in the patient's 
medical record, the date the patient consented or declined consent to consultations, the date of consultation, or, 
if attempts to consult did not succeed, that date and manner of notification to the physician. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of psychotherapy have not been met. Specifically, the record does not include documentation of a 
consultation or an attempt to consult the enrollee's primary/attending physician as required by Medicare rules. 
Therefore, we decided that the Plan does not have to pay for psychotherapy services provided on  
December 27, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the office or other outpatient visit for the evaluation and 
management of a new patient (99204) provided on March 16, 2023. 
 
You asked the Plan to pay for the service. You say that no initial visit has been previously billed. The Plan 
denied your request. The Plan says this new patient evaluation and management (E/M) code denied because 
this edit found another professional claim/face to face service processed for this TIN/specialty in the enrollee's 
claims history within the previous three years.  
 
Review of the received claim images indicates the rendering provider names are different and the claim was 
submitted with taxonomy 207RA0001X, however, per the NPI Registry, that taxonomy is not associated with 
this provider. The taxonomy associated with the provider on the claim is the same as the one submitted on the 
referring claim, which is rendering provider taxonomy 207RC0000X - Internal Medicine  Cardiovascular 
Disease. 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 service have not been met. Therefore, we decided that the Plan 
does not have to pay for the office or other outpatient visit for the evaluation and management of a new patient 
(99204) provided on March 16, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the genetic testing provided on December 1, 2022.   
 
 
You asked the Plan to pay for the genetic testing. You say that this should be paid. The Plan denied your 
request. The Plan says the claim for this molecular pathology testing did not include the required unique 
identifier. 
 
The Plan must follow Medicare rules. The rules say that for molecular diagnostic tests, such as the test at issue, 
the MolDX program requires these tests to be reviewed to determine whether Medicare reasonable and 
necessary requirements are met. When such review is complete, the test is assigned a unique identifier and the 
coverage status is listed in the DEXTM Diagnostics Exchange. 
 
We looked at the file and Medicare rules. Review of the claim does not show that the required unique identifier 
was reported. Based on this information, we decided that Medicare rules for coverage of the genetic testing 
have not been met. Therefore, we decided that the Plan does not have to pay for the genetic testing provided on 
December 1, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a referral to an out-of-network general surgeon. 
 
You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied 
your request. The Plan says the services are available from network providers. 
 
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 referral to an out-of-network general surgeon.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pay for skilled nursing facility (SNF) services received from 
November 4, 2022, to November 21, 2022. 
 
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 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 $125 
copayment per day for days 21-40 of a skilled nursing facility stay.   
You have been asked to pay a $125 copayment per day for the services. This item/service falls within the days 
21-40 of a skilled nursing facility stay benefit category.  Normally, you would have been charged $875 for 
being 8 days over the first 20 days of this admission. However, you were charged only $464.72, as you had met 
your maximum out-of-pocket amount with these 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 pay for skilled nursing 
facility (SNF) services received from November 4, 2022, to November 21, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for office visits provided from August 31, 2022, to 
January 3, 2023. 
 
You asked the Plan to pay for the office visits. You say that the services were medically necessary and have 
been paid in the past. The Plan denied your request. The Plan says because the rendering provider opts out of 
Medicare the provider is not Medicare-qualified, the services are not covered by Medicare and the claim is not 
payable by the Plan.  
 
The Plan must follow Medicare rules. The rules say that no Medicare payment may be made to a beneficiary 
for items or services provided directly by a physician or practitioner who has opted out of the program except 
in cases involving emergencies or urgently needed care. 
 
The services at issue in this appeal were provided in a non-urgent, non-emergent situation by the provider who 
has opted out of the Medicare program. Therefore, we decided that the Plan does not have to pay for office 
visits provided from August 31, 2022, to January 3, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the professional services related to a home sleep study 
provided on February 21, 2023.  
 
You asked the Plan to pay for the sleep study professional services. You say that this should be paid as billed. 
The Plan denied your request. The Plan says the POS code is not valid for this service. 
 
The Plan must follow Medicare rules. Medicare rules say that the Place of Service (POS) code assigned by the 
physician/practitioner for the PC of a diagnostic service shall be the setting in which the beneficiary received 
the TC service.  
 
 We looked at the file and Medicare rules. The enrollee received the TC service in the home setting. As such, 
this is the POS code that should be reported for the professional component. Based on this information, we 
decided that Medicare rules for coverage of the sleep study professional services have not been met. Therefore, 
we decided that the Plan does not have to pay for the professional services related to a home sleep study 
provided on February 21, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an insertion of iris prosthesis, including suture fixation 
and repair or removal of iris, when performed (0617T). 
 
You asked the Plan to pre-approve an iris prosthesis. You say that you are requesting reconsideration of 
coverage for implanting an artificial iris inside the eye. The Plan denied your request. The Plan says this 
procedure is experimental and investigational as this procedure is still being studied for safety and efficacy. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We looked at the file and Medicare rules. The enrollee is not enrolled in a clinical trial. The artificial iris is still 
being studied to see if it is as good or better than standard treatment of aniridia. Based on this information, we 
decided that Medicare rules for coverage of an iris prosthesis have not been met. Therefore, we decided that the 
Plan does not have to pre-approve an insertion of iris prosthesis, including suture fixation and repair or removal 
of iris, when performed (0617T).
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the imaging services (93971-26) provided on January 7, 
2023. 
 
You asked the Plan to pay for the service. You say that the claim is billed correctly. The Plan denied your 
request. The Plan says code 93971-26 is not supported by documentation. 
 
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 asked our coder to carefully review the case file and apply the relevant Medicare rules to determine if the 
Plan was correct in denying the request to pay for the service. Our reviewer found documentation submitted 
was reviewed and does not meet criteria. The procedure report describes bilateral lower extremity duplex scan; 
however, a unilateral duplex scan was billed, with diagnosis R22.42 localized swelling, mass and lump, left 
lower limb. In this case, procedure performed conflicts with procedure and diagnosis reported, and therefore 
cannot be verified.  
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the service have not been met. Therefore, we decided that the Plan does not 
have to pay for the imaging services (93971-26) provided on January 7, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for anesthesia services provided on February 14, 2022. 
 
You asked the Plan to pay for the anesthesia services. You say that the first correct claim was denied and not 
processed, so another claim was submitted. The Plan denied your request. The Plan says the Plan will not 
provide payment for services that were not received within 12 months or 1 calendar year from the date the 
services were furnished. 
 
The Plan follows Medicare rules. The rules say that claims for services furnished on or after January 1, 2010, 
must be filed no later than one calendar year after the date of service. 
 
The record shows that a claim for the anesthesia services was not filed until March 9, 2023. This means that 
more than one calendar year from the date of service had passed before a claim was filed. Therefore, we 
decided that the Plan does not have to pay for anesthesia services provided on February 14, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Zymex transcutaneous electrical nerve stimulation 
(TENS) unit and supplies (E0745, A4556, A4630, A4557) to be provided by an out-of-network (OON) 
provider.  
 
You asked the Plan to pre-approve the Zymex TENS Unit and supplies. You say that the physician feels that 
this enrollee has a medical necessity for this device. The Plan denied your request. The Plan says enrollees 
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 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. Also, incomplete clinical information was 
submitted. The records show that the Plan made multiple attempts to obtain the needed records without 
success. 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 the Zymex transcutaneous electrical nerve stimulation 
(TENS) unit and supplies (E0745, A4556, A4630, A4557) to be provided by an out-of-network (OON) 
provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a battery back-up for oxygen tank (E1399). 
 
You asked the Plan to pre-approve a battery back-up. You say that the electric power is frequently interrupted 
and the enrollee needs to be connected to an oxygen machine 24 hours a day. The Plan denied your request. 
The Plan says this service is not a covered benefit. 
 
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 pre-approve a battery back-up for oxygen tank (E1399).
Appeal type: Transportation
Decision: Favorable

 
We decided that the Plan has to pay for the ambulance transportation provided on December 10, 2021.  
 
You asked the Plan to pay for the ambulance transport. You say that this is not a duplicate claim. The Plan 
denied your request. The Plan says that an appeal review was not performed as the time frame for doing so was 
missed.  
 
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 has not provided a valid denial rationale in this case. The claim was 
denied as a duplicate, but the Plan did not provide any evidence of a paid claim for this date of service. As 
such, we find that the denial of payment is not substantiated. Therefore, we decided that the Plan has to pay for 
the ambulance transportation provided on December 10, 2021.   
 
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again 
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake 
and/or send us the new information. This does not happen often. If we decide to open the case again, we will 
send you a letter.
Appeal type: Inpatient Hospital
Decision: Favorable

 
We decided that the Plan has to pre-approve acute inpatient rehabilitation facility (IRF) admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that the enrollee needs to regain strength before returning 
home. The Plan denied your request. The Plan says that an inpatient rehabilitation facility is not reasonable and 
necessary. 
 
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 found to be medically reasonable and necessary for this enrollee. Our physician reviewer 
found the complexity of the enrollee's nursing, medical and rehabilitation needs requires an acute hospital 
inpatient stay with an interdisciplinary approach to rehabilitation care. The enrollee requires treatment by 
multiple therapies, including physical therapy and occupational therapy for at least 3 hours a day, 5 days a 
week. Documentation states that there is a reasonable expectation that this enrollee will be able to fully 
participate in and benefit from the intensive rehabilitation therapy program provided in an IRF. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have been met. Therefore, we decided that the Plan has to pre-approve 
acute inpatient rehabilitation facility (IRF) admission and services.  
 
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.