Persius/hicric huggingface dataset:
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 96217 billed for date of service August 17, 
2022. 
 
You asked the Plan to pay for procedure code 96217. You say that this service was needed due to a medical 
emergency. The Plan denied your request. The Plan says payment for code 96217 is bundled into payment for 
code G0439. 
 
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 96217 
is a column II code to column I code G0439 with a modifier indicator of 0. The column II code is therefore not payable. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we decided that 
the Plan does not have to pay for procedure code 96217 billed for date of service August 17, 2022.
Appeal type: Step-Therapy
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Synvisc. 
 You asked the Plan to pre-approve Synvisc. You say that the services are necessary. The Plan denied your 
request. The Plan says based on the documentation provided, coverage criteria has not been met. 
 
Medicare covers Part B medications when they are reasonable and necessary but allows health plans to 
implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain 
Part B medications. 
 
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 Synvisc. Our reviewer says that the 
services are not medically necessary. Our physician reviewer found the documentation does not outline 
contraindications or reasons these medications were not considered or that the plans additional required drugs 
would likely be less effective and/or likely have adverse effects for the enrollee. Without the support of the 
documentation, Synvisc is not approved as step criteria has not been met. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Synvisc have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Synvisc.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for ophthalmological services, medical examination and an eye 
refraction provided on December 8, 2022. 
 
You asked the Plan to pay for the ophthalmological services, medical examination and an eye refraction. You 
say that you have met your deductible. 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. Your 
contract with the Plan says that there is a $500 deductible which applies to covered services.  
 
The service you asked the Plan to pay for falls within the vision care benefit category. The Plan has followed 
Medicare rules by clearly disclosing in the contract that there is a $500 deductible which applies to covered 
services. This cost sharing is a contractual obligation that had not been met at the time the ophthalmological 
services, medical examination and an eye refraction was received on December 8, 2022. Therefore, we decided 
that the Plan does not have to pay for ophthalmological services, medical examination and an eye refraction 
provided on December 8, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for code 81345-GZ billed for date of service June 30, 2022. 
 
You asked the Plan to pay for code 81345-GZ. You say that this service was not experimental/investigational, 
so this claim should be paid. The Plan denied your request. The Plan says this code is not covered as billed. 
 
The Plan must follow Medicare rules. Medicare rules say that effective for dates of service on or after July 1, 
2011, all claim lines submitted with the GZ modifier will be automatically denied. You billed the code in 
dispute with the GZ modifier, so no payment can be made for this code.  
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of code 81345-GZ have not been met. Therefore, we decided that the Plan does not have to pay for 
code 81345-GZ billed for date of service June 30, 2022.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home health services provided from November 17, 2022, 
to December 16, 2022. 
 
You asked the Plan to pay for the home health services as billed. You say that you submitted the NOA as 
required. The Plan denied your request. The Plan says the claim has not been billed with the correct admission 
date. The NOA lists an admission date of January 1, 2022, while the claim lists an admission date of July 20, 
2022. 
 The Plan follows Medicare rules. The rules say that for home health services that are continuing from 2021, a 
NOA must be submitted for the first period of care in 2022, using the first date of the period as the admission 
date. Subsequent claims must report this new date as the admission date in order for the claim to be matched to 
the correct NOA.  
 
We reviewed the file and the Medicare rules. We find that the admission date reported on the claim at issue 
does not match the date for the NOA which is filed for the first date in 2022 as required. Based on this 
information, we find that the Medicare rules for payment of the claim at issue have not been met. Therefore, we 
decided that the Plan does not have to pay for the home health services provided from November 17, 2022, to 
December 16, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the wound care supplies provided on November 4, 2022, by 
an out-of-network (OON) provider. 
 
You asked the Plan to pay for the wound care supplies. You say that these supplies are a separately billable 
expense. You say that this does not require separate authorization. You also say that payment should be made 
for these supplies. The Plan denied your request. The Plan says prior authorization was not obtained. 
 
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 in this case is not 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 the wound care supplies provided on November 4, 2022, by an 
out-of-network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code A6021 provided on December 7, 2022. 
 
You asked the Plan to pay for procedure code A6021. 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. 
 
We find that CPT code A6021 is not supported in the medical record. Specifically, code A6021 is a surgical 
dressing code and was billed without an A1-A9 modifier. Based on this information, we decided that Medicare 
rules for coverage of procedure code A6021 have not been met. Therefore, we decided that the Plan does not 
have to pay for procedure code A6021 provided on December 7, 2022.
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pay for chronic care management services (procedure code 99490) rendered on 
March 20, 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 that the records do not support documentation of the billing provider having an initiating face-to-
face visit separate of the CCM service. 
 
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 99490 is "Chronic care management (CCM) services with the following required elements: multiple (two 
or more) chronic conditions expected to last at least 12 months, or until the death of the patient, chronic 
conditions that place the patient at significant risk of death, acute exacerbation/decompensation, or functional 
decline, comprehensive care plan established, implemented, revised, or monitored; first 20 minutes of clinical 
staff time directed by a physician or other qualified health care professional, per calendar month." 
 
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 supported by the medical records. Our reviewer found that CPT code 99490 is supported by the 
medical record. The documentation states that 20:01 minutes were spent by the staff managing the enrollee's 
chronic conditions. The record supports that the services described by 99490 were 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 been met. Therefore, we decided that the Plan has to pay for 
chronic care management services (procedure code 99490) rendered on March 20, 2022.  
 
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: Favorable

 
We decided that the Plan has to pay for procedure code 99223 billed for date of service January 3, 2023. 
 
You asked the Plan to pay for procedure code 99223. You say that the services at issue were billed correctly. 
The Plan denied your request. The Plan says that rules for payment have not been met because you have 
reported an inpatient procedure code for outpatient observation services. 
 
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 99223 is: Initial hospital inpatient or observation care, per day, for the evaluation and management of a 
patient, which requires a medically appropriate history and/or examination and high level of medical decision 
making. When using total time on the date of the encounter for code selection, 75 minutes must be met or 
exceeded. 
 
We find that CPT code 99223 is supported in the case record. Specifically, the Plan's denial reason is no longer 
valid in 2023. There is no longer a difference between inpatient services and outpatient observation services for 
the code at issue. Based on this information, we decided that Medicare rules for coverage of procedure code 
99223 have been met. Therefore, we decided that the Plan has to pay for procedure code 99223 billed for date 
of service January 3, 2023.  
 
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: Favorable

 
We decided that the Plan has to pre-approve a prosthetic leg with an electronic knee feature (L5828, L5845, 
L5848, L5856, L5694, L5988, L5984). 
 
You asked the Plan to pre-approve the services. You say that this is medically necessary. The Plan denied your 
request. The Plan says that this is not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that services are covered if 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 services. Our reviewer says that the 
requested items/services are considered medically reasonable and necessary in this case. Our physician 
reviewer found that the plan tacitly acknowledges that you are a K3 ambulator in that they have already 
approved L5981. This item is only covered for people whose functional level is K3 or above. Therefore, L5986 
would also be covered, as that item only requires a K2 level. Additionally, the medical records includes thorough discussions of your K3 activity levels in both the certified prosthetist/orthotist (CPO) and surgeon's 
notes. There are also explicit discussions of need for the microprocessor knee and the inadequacy of a 
mechanical knee to meet your needs. It is discussed in a way that is frankly above and beyond the regulatory 
requirement for coverage of a microprocessor knee. Lastly, Medicare puts no specific restrictions on the use of 
L5694, deferring by default to the prosthetists judgement if this inexpensive component is needed to ensure 
proper suspension  the need for which is, at any rate, also documented in the record as part of the overall 
strategy to absorb the various rotary forces you are exposed to in your athletic, K3-level daily function. 
 
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 services have been met. Therefore, we decided that the Plan has to pre-
approve a prosthetic leg with an electronic knee feature (L5828, L5845, L5848, L5856, L5694, L5988, L5984).  
 
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 procedure code 96127 billed for date of service November 
17, 2022. 
 
You asked the Plan to pay for procedure code 96127. You say that this should be paid for. The Plan denied 
your request. The Plan says payment for code 96127 is bundled into payment for code G0439. 
 
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 96127 is a column II code to column I code G0439 with a modifier indicator of 0. The column II code is therefore not 
payable. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we decided that 
the Plan does not have to pay for procedure code 96127 billed for date of service November 17, 2022.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a visual field assessment provided on January 20, 2023. 
 
You asked the Plan to pay for the visual field assessment. You say that the visual field assessment was 
medically necessary. The Plan denied your request. The Plan says the visual field assessment is not considered 
reasonable or necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that the provider, supplier, or beneficiary, as 
appropriate, must furnish to the intermediary or carrier sufficient information to determine whether payment is 
due and the amount of payment. 
 
We looked at the file and Medicare rules. Based on this information, we decided that there is insufficient 
information in the record to determine if Medicare rules for coverage of the visual field assessment have been met. The medical records have not been provided for review. Therefore, we decided that the Plan does not have 
to pay for a visual field assessment provided on January 20, 2023.
Appeal type: Hospice
Decision: Unfavorable

 
We decided that the Plan does not have to pay for subsequent nursing facility care provided on 
December 12, 2022. 
 
You asked the Plan to pay for the subsequent nursing facility care. The Plan denied your request. The Plan says 
Original Medicare is responsible for payment. 
 Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice 
services. Medicare hospice pays for claims related to the terminal illness. The rules say that the Plan may direct 
the provider to bill Medicare directly for these services.  
 
The enrollee was under the Medicare hospice benefit for the dates of service at issue in this appeal. Therefore, 
we decided that the Plan does not have to pay for subsequent nursing facility care provided on  
December 12, 2022.
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pre-approve chiropractic manipulative treatments (98940). 
 
You asked the Plan to pre-approve these services. You say that you are requesting a reconsideration of the 
Plan's denial. The Plan denied your request. The Plan says that you do not meet Medicare criteria for coverage 
of the requested services. 
 
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. Specifically, the Plan has stated that you do not meet Medicare criteria for 
coverage of the chiropractic manipulative treatments requested in this case. However, the Plan provides 
supplemental coverage of up to $500 per year to spend on routine acupuncture services, chiropractic services, 
vision services, dental services, and hearing services under the Flex allowance benefit. The Plan has not 
indicated that you have exhausted the maximum allowable Flex benefit for this calendar year. The Plan has not 
substantiated their denial; therefore, we must find in your favor. The Plan must authorize chiropractic services 
up to the maximum allowable flex benefit. Any costs that exceed this benefit will be your responsibility.  
Therefore, we decided that the Plan has to pre-approve chiropractic manipulative treatments (98940).  
 
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 pay for the water circulating heat pad with pump (E0217) provided 
from August 4, 2022, to August 25, 2022. 
 
You asked the Plan to pay for the water circulating heat pad with pump. You say that this item is medically 
necessary for the enrollee. You also say that the medical literature supports the efficacy of this item. The Plan 
denied your request. The Plan says the requested item is not a covered benefit. 
 
The Plan must follow Medicare rules. Medicare rules say that that it has not been established that a water 
circulating heat pad with pump is reasonable and necessary compared to a standard electric heating pad and 
therefore will be denied as not reasonable and necessary.  
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the water circulating heat pad with pump have not been met. Therefore, we decided that the Plan does not have to pay for the water circulating heat pad with pump (E0217) provided from August 4, 2022, to 
August 25, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the refractive services provided on December 19, 2022. 
 
You asked the Plan to pay for the billed services. You say that there was a referral for this enrollee. The Plan 
denied your request. The Plan says the service is not covered. 
 
The Plan must follow Medicare rules. The rules say that Medicare does not cover routine vision services and 
eyewear.  
 
We looked at the file and the rules. The refractive services are considered routine vision care and not covered 
when provided with a medical exam. Therefore, we decided that the Plan does not have to pay for the refractive 
services provided on December 19, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the wearable automatic external defibrillator (K0606) 
provided on December 5, 2022, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for the Zoll life vest. You say that please review and reprocess the claim for 
payment. 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 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 wearable automatic external defibrillator 
(K0606) provided on December 5, 2022, by an out-of-network (OON) provider.