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

 
We decided that the Plan does not have to pay for anesthesia services rendered on July 15, 2022. 
 
You asked the Plan to pay for the services. You say that the services were denied correctly. The Plan denied 
your request. The Plan says you do not agree with this denial. 
 
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 pay for the services. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found that in this case, the record indicates that you underwent radiofrequency ablation for back pain. The 
record provided does not the unequivocally and clearly document the medical necessity of sedation in your 
specific clinical scenario. The elements of the coverage criteria are not satisfied. 
 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 not been met. Therefore, we decided that the Plan does not 
have to pay for anesthesia services rendered on July 15, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for initial nursing facility care (code 99305) provided on 
September 1, 2021. 
 
You asked the Plan to pay for the initial nursing facility care. You say that the claim was filed timely. The Plan 
denied your request. The Plan says the provider did supply evidence that claim was attempted to be billed once 
before, but provider failed to re-file claim within timely file, despite being timely notified of rejection of initial 
claim. 
 
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 initial nursing facility care was not filed until January 18, 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 initial nursing facility care (code 99305) provided 
on September 1, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for physician's services provided on December 30, 2021. 
 
You asked the Plan to pay for the physician's services. You say that the claim was filed timely. The Plan denied 
your request. The Plan says the provider did supply evidence that claim was attempted to be billed once before, 
but provider failed to re-file claim within timely file, despite being timely notified of rejection of initial claim. 
 
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 physician's services was not filed until January 18, 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 physician's services provided on December 30, 2021.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for home health services provided from April 23, 2022, to July 
21, 2022. 
 You asked the Plan to pay for the home health services. You say that you believe you timely filed your NOA. 
The Plan denied your request. The Plan says the NOA was not received timely. As such, this final claim was 
correctly denied. 
 
The Plan follows Medicare rules. The rules say that an NOA must be submitted within 5 days of the start of 
care date for home health services. NOAs which are received more than 30 days from the timely filing date 
result in no payment being made for the episode of care.  
 
In this case, the start of care date is April 23, 2022. The NOA was not received by the Plan until July 22, 2022. 
As more than 30 days passed between the timely filing date and the NOA receipt, no payment can be made on 
this claim. Therefore, we decided that the Plan does not have to pay for home health services provided from 
April 23, 2022, to July 21, 2022.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 25600 and 99285 rendered on June 30, 
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 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 25600: 
 
Closed treatment of distal radial fracture (eg, Colles or Smith type) or epiphyseal separation, includes closed treatment of fracture of ulnar styloid, when performed; without manipulation 
 
CPT 99285: 
 
Emergency department visit for the evaluation and management of a patient, which requires these 3 key 
components within the constraints imposed by the urgency of the patient's clinical condition and/or mental 
status: A comprehensive history; A comprehensive examination; and Medical decision making of high 
complexity. Counseling and/or coordination of care with other physicians, other qualified health care 
professionals, or agencies are provided consistent with the nature of the problem(s) and the patient's and/or 
family's needs. Usually, the presenting problem(s) are of high severity and pose an immediate significant threat 
to life or physiologic function 
 
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 in terms of CPT 25600, the 
procedure report documents left upper extremity splint applied to left forearm. There is a more appropriate 
code to report for splint application. Therefore, this procedure cannot be verified. In terms of CPT 99285, the 
emergency department visit shows a detailed history and medical decision making of high complexity. In this 
case, there is a more appropriate code to report for service provided. 
 
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 procedure codes 25600 and 99285 rendered on June 30, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for leg rests (K0195) provided on June 3, 2022. 
 
You asked the Plan to pay for the leg rests. You say that this item was medically necessary. The Plan denied 
your request. The Plan says the claim was not billed with a correct modifier. 
 
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 K0195 is not supported in the medical record. Specifically, modifier NU for new 
equipment was billed with an equipment code categorized as a capped rental item. Based on this information, 
we decided that Medicare rules for coverage of the leg rests have not been met. Therefore, we decided that the 
Plan does not have to pay for leg rests (K0195) provided on June 3, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for initial nursing facility care provided from  
September 22, 2021, to October 6, 2021. 
 
You asked the Plan to pay for the initial nursing facility care. You say that the claims were filed timely. The 
Plan denied your request. The Plan says the provider did supply evidence that claim was attempted to be billed 
once before, but provider failed to re-file claim within timely file, despite being timely notified of rejection of 
initial claim. 
 
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 initial nursing facility care was not filed until January 18, 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 initial nursing facility care provided from 
September 22, 2021, to October 6, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for chronic care management services (procedure code 99490) 
rendered on July 25, 2022. 
 
You asked the Plan to pay for the services. You say that the claim should be reprocessed and paid. The Plan 
denied your request. The Plan says the attached care plan is not complete or comprehensive. 
 
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 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 not supported by the medical records. Our reviewer found that the procedure report does not 
include enough information to confirm criteria in code description to include a comprehensive care plan 
established, implemented, revised, or monitored. The medical record does not include historical documentation 
to confirm criteria has been met. 
 
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 chronic care management services (procedure code 99490) rendered on July 25, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit and related services provided on February 02, 
2023. 
 
You asked the Plan to pay for an office visit and related services. You say that this service is supported in the 
records. 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 an office visit and 
related services provided on February 02, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for subsequent nursing facility care provided on  
August 24, 2021. 
 
You asked the Plan to pay for the subsequent nursing facility care. You say that the claim was filed timely. The 
Plan denied your request. The Plan says the provider did supply evidence that claim was attempted to be billed 
once before, but provider failed to re-file claim within timely file, despite being timely notified of rejection of 
initial claim. 
 
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 subsequent nursing facility care was not filed until January 18, 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 subsequent nursing facility care provided on 
August 24, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for initial nursing facility care provided on December 15, 2021. 
 
You asked the Plan to pay for initial nursing facility care. You say that the claim was filed timely. The Plan 
denied your request. The Plan says the provider did supply evidence that claim was attempted to be billed once 
before, but provider failed to re-file claim within timely file, despite being timely notified of rejection of initial 
claim. 
 
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 initial nursing facility care was not filed until January 18, 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 initial nursing facility care provided on December 15, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a home ventilator (E0466). 
 
You asked the Plan to pre-approve a home ventilator. You say that a home ventilator is a medical necessity for 
the enrollee. The Plan denied your request. The Plan says a home ventilator is not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that ventilators may be covered when they are medically 
necessary for patients who have neuromuscular disease, thoracic restrictive diseases, and chronic respiratory 
failure due to COPD. 
 
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 a home ventilator. Our reviewer says 
that a home ventilator is not medically reasonable and necessary in this case. Our physician reviewer found that the enrollee has severe COPD and was recently hospitalized with an exacerbation. Multiple arterial blood gases 
(ABGs) in the records show varying degrees of acute on chronic carbon dioxide (CO2) retention, but there is 
no ABG done while stable to confirm chronic CO2 retention. If that is present, the enrollee may benefit from 
BiPAP with average volume-assured pressure support (AVAPS) during sleep as an outpatient. Medicare does 
not cover a home ventilator when used at settings that can be provided with BiPAP. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of a home ventilator have not been met. Therefore, we decided that the Plan does 
not have to pre-approve a home ventilator (E0466).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for physician's services provided on September 14, 2021, and 
September 22, 2021. 
 
You asked the Plan to pay for the physician's services. The Plan denied your request. The Plan says the 
provider did supply evidence that claim was attempted to be billed once before, but provider failed to re-file 
claim within timely file, despite being timely notified of rejection of initial claim. 
 
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 physician's services was not filed until January 18, 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 physician's services provided on September 14, 2021, and 
September 22, 2021.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the cost share for the specialist office visit, diagnostic services 
and the injections provided from November 18, 2022, to December 1, 2022. You asked the Plan to waive the cost share for the specialist office visit, diagnostic services and the injections. 
You say that you do not understand why you are being charged. 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 services obtained from a specialist. Your contract with the Plan also clearly says that you must 
pay a $20 copayment for Medicare-covered non-radiological diagnostic services. Your contract with the Plan 
also clearly says that you must pay a $75 copayment for Medicare-covered radiological diagnostic services. 
Your contract with the Plan also clearly says that you must pay 20% coinsurance for Medicare-covered Part B 
drugs. 
 
The record shows these claims were approved and you are responsible for a cost sharing amount. A specialist 
office visit falls within the physician/practitioner services, including doctors office visits benefit category. A 
bladder assessment, an ultrasound, and a stress test fall within the outpatient diagnostic tests and therapeutic 
services and supplies benefit category. Injections fall within the Medicare Part B prescription drugs benefit 
category. 
 
Date of Service Item Allowed 
Amount 
Copayment 20% Coinsurance 
November 18, 2022 Electrocardiogram $15.07 $15.07  
November 29, 2022 Office visit $5.80 $5.80  
November 29, 2022 Assessment of bladder $14.20 $14.20  
November 29, 2022 Limited ultrasound $58.30 $58.30  
November 29, 2022 Complete ultrasound $16.70 $16.70  
December 1, 2022 Heart stress test $20.00 $20.00  
December 1, 2022 Regadenoson injection $245.40  $49.08 
December 1, 2022 Tc-99m injection $17.50  $3.50 
December 1, 2022 Technetium injection $164.00  $32.80 
 
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 cost share for the specialist office visit, diagnostic services and the 
injections provided from November 18, 2022, to December 1, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a ventilator. 
 
You asked the Plan to pre-approve a ventilator. 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. 
 
The Plan must follow Medicare rules. The rules say that ventilators may be covered when they are medically 
necessary for patients who have neuromuscular disease, thoracic restrictive diseases, and chronic respiratory 
failure due to COPD. 
 
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 a ventilator. Our reviewer says that the 
services are not medically necessary.  Our physician reviewer found the provided primary source documentation does not contain sufficient detailed 
information in the medical record to justify the treatment selected. The enrollee could be treated with a bilevel 
positive airway pressure (BiPAP) machine with ventilator-associated pneumonia (VAPS) capability and failure 
of such a device has not been documented. The plan has indicated coverage for such a device is available upon 
request. The elements of the coverage criteria are not satisfied. The requested service cannot be recommended. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of a ventilator have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a ventilator.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the dental services on December 1, 2022. 
 
You asked the Plan to pay for the dental services. You say that you would like to request reconsideration of the 
denied claim. The Plan denied your request. The Plan says your benefit for the requested item or service has 
already been exhausted. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, certain limitations apply. The record 
shows your benefit for the requested item or service was exhausted on date of service November 21, 2022. 
Therefore, we decided that the Plan does not have to pay for the dental services on December 1, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the subsequent hospital care provided on September 08, 
2022. 
 
You asked the Plan to pay for the subsequent hospital care. You say that the records provided support medical 
necessity. 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 the subsequent hospital 
care provided on September 08, 2022.