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

 
We decided that the Plan does not have to reimburse you for a psychiatric diagnostic evaluation and 
psychotherapy services provided from April 10, 2023 to April 26, 2023. 
 
You asked the Plan to reimburse you for the psychiatric diagnostic evaluation and psychotherapy services. You 
say that the services were medically necessary. The Plan denied your request. The Plan says this provider has 
opted out of Medicare. 
 
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 reimburse you for 
a psychiatric diagnostic evaluation and psychotherapy services provided from April 10, 2023 to April 26, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for evaluation and management services (procedure code 99213-
25) rendered on October 7, 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 Current Procedural Terminology (CPT) code 99213-25 (1 units) remains 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 99213 is "Office or other outpatient visit for the 
evaluation and management of an established patient, which requires a medically appropriate history and/or 
examination and low level of medical decision making. When using time for code selection, 20-29 minutes of 
total time is spent on the date of the encounter." 
 
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 there is no clear documentation of 
an independent visit significantly identifiable from the CPT 20610 in this case. 
 
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 evaluation and management services (procedure code 99213-25) rendered on October 7, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve ostomy deodorant. 
 
You asked the Plan to pre-approve ostomy deodorant. You say that you feel these supplies are medically 
necessary. The Plan denied your request. The Plan says the requested item 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 ostomy deodorant.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services and office visits provided in Spain on 
January 19, 2023, to February 9, 2023. 
 
You asked the Plan to pay for the laboratory services and office visits. You say that you were traveling to Spain 
for two months and needed to have your blood levels monitored due to a diagnosis of cancer. The Plan denied 
your request. The Plan says this provider was out-of-network and were not urgent/emergent in nature. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services furnished outside of the 
United States are only covered under limited, specified circumstances. The Plan has a worldwide coverage 
benefit that goes beyond Medicares coverage. For that reason, the Plans rules apply to this case. The Plan 
covers worldwide emergency and urgent care services. Urgently needed services are defined as those needed 
because of an unforeseen illness or condition and it is not reasonable to get the services from the Plan. 
 
We looked at the file, Medicare rules, the Plans rules, and our physicians review. These services do not fall 
within any of Medicares specified circumstances for coverage of services outside of the United States. 
Additionally, these services do not meet the Plans rules for coverage because they were not emergent or urgent 
in nature. Therefore, we decided that the Plan does not have to pay for the laboratory services and office visits 
provided in Spain on January 19, 2023, to February 9, 2023.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ultrasound of the abdominal (76700) provided on April 
19, 2023. 
 
You asked the Plan to pay for the ultrasound. You say that medical records submitted supports code 76700-59 
and should be paid. The Plan denied your request. The Plan says code 76700-59 remains not supported. This 
code is included in Current Procedural Terminology (CPT) code 93976; this means, it can't be separately 
reimbursed. The medical records received do not support that the procedure or service was distinct or 
independent from other services performed; this means the use of the 59 modifier is not supported. 
 
The Plan must follow Medicare rules. The rules state that providers may bill services with a -59 modifier if the 
service billed with the modifier indicates a distinct procedural service.   
 
We asked our coding 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 pay for the ultrasound. Our coder says that the medical records submitted do not support code 76700 with appended modifier 59 as being a distinct procedural 
service to bypass NCCI Edit with a duplex scan performed on same date of service. Therefore, code 76700 
cannot be verified. 
 
We looked at this coder review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the ultrasound have not been met. Therefore, we decided that the Plan does not 
have to pay for the ultrasound of the abdominal (76700) provided on April 19, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve prosthesis additions identified with codes L5987, 
L5828, L5845, L5848, L5850, L5856, L5925, L5984, L5987, and L5984. 
 
You asked the Plan to pre-approve prosthesis additions. You say that you disagree with the Plan's denial. The 
Plan denied your request. The Plan says the requested items are not medically necessary. 
 
The Plan follows Medicare rules. Medicare rules say that orthosis additions are only covered for certain 
indications. 
 
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 orthosis additions. Our reviewer says 
that the documentation does not support that the requested items are medically reasonable or necessary. Our 
physician reviewer found the enrollee is stated to have K3 potential and can walk 400 feet with prosthesis. The 
enrollee is noted to have arthralgia, hand pain and will be referred to pain management. A Proteor Shockwave 
Prosthetic K3 foot coded as L5987 and L5984 is not medically necessary. The physician documentation does 
not support that the enrollee is participating in high impact activities or is a K3 ambulator that would require a 
shock reducing pylon or Proteor K3 foot. The requested feet with shock reducing pylon exceeds the enrollees needs. L5987, L5828, L5845, L5848, L5850, L5856, L5925 (Freedom Quattro by Proteor) exceed the 
enrollees medical needs. The documentation does not support that the enrollee is a K3 ambulator given that a 
Group 2 power wheelchair is noted to be medically necessary. The documentation does not support that the 
enrollee requires a microprocessor knee over a mechanical knee. The requested knee appears to exceed the 
enrollees needs. Additionally, the enrollee's current knee and feet are still under warranty. Therefore, the 
enrollee does not meet criteria for the requested items. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of orthosis additions have not been met. Therefore, we decided that the Plan does 
not have to pre-approve prosthesis additions identified with codes L5987, L5828, L5845, L5848, L5850, 
L5856, L5925, L5984, L5987, and L5984.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for anesthesia services provided on January 7, 2021. 
 
You asked the Plan to pay for the anesthesia services. You say that the patient and the facility provided 
incorrect insurance information, which created the delay in filing the claim timely.  The Plan denied your 
request. The Plan says the claim was untimely, and the submission did not meet the exception criteria 
guidelines outlined in 42 CFR Section 424.44.  
 
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 April 20, 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 January 7, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for medical equipment provided on May 26, 2023. 
 
You asked the Plan to pay for the medical equipment. You say that the diagnoses billed are covered. The Plan 
denied your request. The Plan says two of the billed diagnosis codes cannot be reported together. 
 
The Plan follows Medicare rules. The rules say that providers must comply with ICD-10-CM coding 
guidelines. One such guideline indicates that certain diagnosis codes have an Excludes1 note which lists other 
diagnosis codes with which they cannot be reported.   
In this case, we have confirmed that J42 has an Excludes1 note in relation to J44.9. This means that the two 
diagnosis codes cannot be reported together. Based on this information, we decided that the Medicare billing 
rules for the medical equipment have not been met. Therefore, we decided that the Plan does not have to pay 
for medical equipment provided on May 26, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve genicular nerve blocks. 
 
You asked the Plan to pre-approve the injections. You say that you are appealing with supporting records. The 
Plan denied your request. The Plan says the criteria for coverage have not been met. 
 
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 injections. Our reviewer says that 
the requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found that genicular nerve blocks and genicular nerve ablation are considered 
experimental/investigational and are not medically necessary for the treatment of chronic knee pain. 
 
 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 injections have not been met. Therefore, we decided that the Plan does not 
have to pre-approve genicular nerve blocks.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve additional routine transportation services. 
 
You asked the Plan to pre-approve the additional routine transportation services. You say that the services are 
medically necessary. The Plan denied your request. The Plan says you have exhausted your yearly limit. 
 
 
 Medicare does not cover transport in a vehicle that is not an ambulance. However, the Plan offers a 
transportation benefit that exceeds Medicare coverage. For that reason, the Plans coverage rules apply in this 
case. The Plan covers a maximum of 36 trips per year.  
 
We looked at your request, the records in the case file, and the rules. Based on this information, we decided 
that you have exhausted the Plan maximum benefit for coverage of routine transportation. Therefore, we 
decided that the Plan does not have to pre-approve additional routine transportation services.
Appeal type: Surgery
Decision: Favorable

 
We decided that the Plan has to pay for procedure codes 36556 and 76937 rendered on May 19, 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 that the records do 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 
the denied codes is: 
 
CPT 36556: 
 
Insertion of non-tunneled centrally inserted central venous catheter; age 5 years or older 
 
CPT 76937: 
 
Ultrasound guidance for vascular access requiring ultrasound evaluation of potential access sites, 
documentation of selected vessel patency, concurrent realtime ultrasound visualization of vascular needle 
entry, with permanent recording and reporting (List separately in addition to code for primary procedure) 
 
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 the documentation supports that the 
services in question were rendered and appropriately coded.   There is satisfactory documentation that a central 
line was placed in the internal jugular vein.  There is satisfactory documentation that the line was placed 
centrally.  As most central lines placed perioperatively are not placed under fluoroscopic guidance, the exact 
location of the tip cannot be documented, and it is not reasonable to require this information to justify 
billing.  However, in this case, there is x-ray documentation of the catheter tip in the right brachial-cephalic 
vein on a post operative chest x-ray confirming central placement. Additionally, there is documentation that 
ultrasound guidance for access was utilized demonstrating patency of the vein and including recording of 
imaging in the materials reviewed. 
 
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 
procedure codes 36556 and 76937 rendered on May 19, 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: Unfavorable

 
We decided that the Plan does not have to pay for the portable oxygen concentrator provided on January 9, 
2023, to May 9, 2023. 
 
You asked the Plan to pay for oxygen concentrator. You say that you should have not cost share for the 
requested items. The Plan denied your request. The Plan says this is not approved because it exceeds the 
oxygen equipment rental limit of 36 months. 
 
The Plan must follow Medicare rules. The rules say Medicare reimbursement for oxygen equipment is limited 
to 36 monthly rental payments. Payment for accessories (e.g., cannula, tubing, etc.), delivery, back-up 
equipment, maintenance, and repairs is included in the rental allowance. 
 
The file shows that rental of this oxygen equipment from a non-participating supplier is limited to 10 months 
after renting this equipment for 26 months or more from a participating provider; therefore, this specific 
nonparticipating equipment rental exceeds that 10-month allowed and is not covered. Therefore, we decided 
that the Plan does not have to pay for the portable oxygen concentrator provided on January 9, 2023, to May 9, 
2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the urine polymerase chain reaction (PCR) panel testing 
provided on April 24, 2023, and billed with codes 87900, 87500, 87998, and 87481. 
 
You asked the Plan to pay for the urine PCR panel. You say that this testing was medically necessary. The Plan 
denied your request. The Plan says this testing should be billed with a single panel code. 
 
The Plan must follow Medicare rules. Medicare rules say that a panel cannot be unbundled and billed as 
individual components. 
 
We looked at the file and Medicare rules. This test was not billed with a single panel code as required. Based 
on this information, we decided that Medicare rules for coverage of the urine PCR panel have not been met. 
Therefore, we decided that the Plan does not have to pay for the urine polymerase chain reaction (PCR) panel 
testing provided on April 24, 2023, and billed with codes 87900, 87500, 87998, and 87481.
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pay for evaluation and management services (procedure code 99213-23) 
rendered on February 21, 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 that Current Procedural Terminology (CPT) code 99213-25 remains 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 99213 is "Office or other outpatient visit for the evaluation and management of an established patient, 
which requires a medically appropriate history and/or examination and low level of medical decision making. 
When using time for code selection, 20-29 minutes of total time is spent on the date of the encounter." 
 
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 the medical notes documentation a 
history, exam, and decision making considered in line with the definition of CPT 99213. Additionally, the 
records support CPT 99213 as independent of CPT 36482 in this case. 
 
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 
evaluation and management services (procedure code 99213-23) rendered on February 21, 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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for moderate sedation services (99152) provided on April 28, 
2023. 
 
You asked the Plan to pay for moderate sedation services. You say that this is documented in the records. The 
Plan denied your request. The Plan says the time spent on this service is not documented. 
 
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 99152 is moderate sedation services provided by the 
same physician or other qualified health care professional performing the diagnostic or therapeutic service that 
the sedation supports, requiring the presence of an independent trained observer to assist in the monitoring of 
the patient's level of consciousness and physiological status; initial 15 minutes of intraservice time, patient age 
5 years or older. 
 We find that CPT code 99152 is not supported in the medical record. Specifically, the submitted records do not 
document the intraservice time. Based on this information, we decided that Medicare rules for coverage of 
moderate sedation services have not been met. Therefore, we decided that the Plan does not have to pay for 
moderate sedation services (99152) provided on April 28, 2023.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve surgical service provided by an opted out physician on 
December 15, 2022. 
 
You asked the Plan to pre-approve surgery service. You say that the physician does not opt out of Medicare. 
The Plan denied your request. The Plan says this physician has opted out of Medicare and is not eligible for 
payment. 
 
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 pre-approve 
surgical service provided by an opted out physician on December 15, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an electrocardiogram provided on May 12, 
2023. 
 
You asked the Plan to waive the copayment for an electrocardiogram. You say that you disagree with the 
copayment. 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 $20 
copayment for outpatient diagnostic tests and therapeutic services and supplies. 
 
You have been asked to pay a $20 copayment for an electrocardiogram. This item/service falls within the 
outpatient diagnostic tests and therapeutic services and supplies benefit category. This means that you have 
been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. However, since the allowed amount is less than the 
standard copayment, you only owe $15.98. Therefore, we decided that the Plan does not have to waive the 
copayment for an electrocardiogram provided on May 12, 2023.