Persius/hicric huggingface dataset:
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a replacement K3 foot. 
 
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 products under warranty cannot be replaced. 
 
The Plan must follow Medicare rules. The rules say that Medicare does not cover replacement equipment when 
the item is under warranty. 
 
We looked at the file and Medicare rules. The file shows that the enrollee's current K3 foot is still under 
manufacturer warranty. Based on this information, we decided that Medicare rules for coverage of these 
services have not been met. Therefore, we decided that the Plan does not have to pre-approve a replacement K3 
foot.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve additional power wheelchair accessories (E2311, 
E2313, E2377). 
 
You asked the Plan to pre-approve the accessories. You say that this is medically necessary. The Plan denied 
your request. The Plan says the enrollee's upper limb strength and function are adequate for the enrollee to be 
able to control the power options using their own switches which are included in the allowance of these power 
options. 
 
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 accessories. Our reviewer says that 
the requested items are not considered medically reasonable and necessary in this case. Our physician reviewer 
found that the medical record documentation from the physician does not support that the enrollee requires all 
of the upgraded electronics requested. The provided records document that the enrollee has 5-/5 right upper 
extremity strength and is independent with eating thus indicating he has adequate upper extremity strength and 
function to operate the wheelchair's power options with their own switches.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the accessories have not been met. Therefore, we decided that the Plan does not 
have to pre-approve additional power wheelchair accessories (E2311, E2313, E2377).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the outpatient office visit (99203) and injection, ceftriaxone 
sodium (J0696) provided on August 22, 2023, by an out-of-network (OON) provider.  
 
You asked the Plan to pay for the office visit. You say that please see the attached Medical Records for your 
review which justifies the office visit 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 outpatient office visit (99203) and injection, 
ceftriaxone sodium (J0696) provided on August 22, 2023, by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 69210 billed for date of service October 24, 
2022.  
 
You asked the Plan to pay for procedure code 69210. The Plan denied your request. The Plan says payment for 
code 69210 is bundled into payment for code 92557. 
 
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 69210 is a column two code to column one code 92557 with a modifier indicator of 0. The column two 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 69210 billed for date of service October 24, 
2022.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the short-latency somatosensory evoked potential study and 
continuous intraoperative neurophysiology monitoring billed with codes 95938 and 95940 provided on 
February 28, 2023. 
 
You asked the Plan to pay for the tests. You say that the services were billed correctly and should be paid. The 
Plan denied your request. The Plan says code 95938 is included in the facility payment and is not separately 
payable, as this code was reported with modifier TC, which is paid the facility. In addition, code 95940 is an 
add-on code that can't be paid unless the primary procedure (95938) is also paid. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. Technical components must be billed by the 
facility where the enrollee was an inpatient or outpatient and are not separately payable to the lab. 
 
 The records indicate that this service was provided to the enrollee while an inpatient or outpatient. Per the 
Physician Fee Schedule, there is a Professional/Technical indicator of 1 for CPT code 95938. This means there 
is both a professional and technical component for this code. In this case, an appropriate modifier to indicate 
the professional component (-26) has not been billed with CPT code 95938. Based on this information, we 
decided that Medicare rules for coverage of this code have not been met. In addition, we have confirmed that 
code 95940 is an add-on code for code 95938, and the primary code was denied payment. Based on the claim 
submitted, Medicare billing criteria have not been met. Therefore, we decided that the Plan does not have to 
pay for the short-latency somatosensory evoked potential study and continuous intraoperative neurophysiology 
monitoring billed with codes 95938 and 95940 provided on February 28, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the outpatient office visit (99202) and 
Chiropractic Manipulative treatment (98941) provided June 26, 2023, to July 5, 2023. 
 
You asked the Plan to waive the copayment for the chiropractic services. You say that you are being charged a 
$75 copay when you should only be charged a $20 copay. The Plan denied your request. The Plan says this 
cost sharing was charged correctly. Office visits are not covered when rendered by this provider type.  
 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 $20 copy 
for each Medicare covered chiropractic visit.   
 
You have been asked to pay $115 ($75 office visit + $40 copay) for the chiropractic services. This item/service 
falls within the Chiropractic services benefit category. The only chiropractic service Medicare covers is manual 
manipulation of the spine to correct a subluxation. The office visit is not covered when rendered by a 
chiropractor. This means that you have been asked to pay the correct amount based on your contract with the 
Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, 
we decided that the Plan does not have to waive the copayment for the outpatient office visit (99202) and 
Chiropractic Manipulative treatment (98941) provided June 26, 2023, to July 5, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the specialist office visit provided on June 
15, 2023. 
 
You asked the Plan to waive the copayment for the specialist office visit. You say that you are requesting the 
copayment be waived. 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 $45 
copayment for an in-network specialist office visit.  You have been asked to pay a $45 copayment for the specialist office visit. This item/service falls within the 
physician/practitioner services, including doctors office visits benefit category. This means that you have been 
asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual 
obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have 
to waive the copayment for the specialist office visit provided on June 15, 2023.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve additional occupational therapy (OT) services.  
 
You asked the Plan to pre-approve the therapy services. You say that the additional OT services are medically 
necessary.  The Plan denied your request. The Plan says the enrollee does not meet the criteria for the 
additional OT services.  
 
The Plan must follow Medicare rules. The rules say that Medicare pays for medically necessary outpatient 
therapy. 
 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 therapy services. Our reviewer says 
that skilled services are not necessary to restore or maintain function or to prevent deterioration of the enrollee's 
condition. Our physician reviewer found the additional requested therapy is not generally accepted as specific 
and effective therapy for the enrollees condition beyond what was approved by the health plan. The records do 
not demonstrate that the unique skills of a professional therapist are required to provide treatment safely and 
effectively, that the services can be safely and effectively performed only by a therapist, or by or under the 
supervision of a therapist. The enrollee has had instruction in a home exercise program. The enrollee's 
functional level does not require ongoing skilled professional therapy. 
 
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 therapy services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve additional occupational therapy (OT) services.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the computed tomography (CT scan) of the abdomen and 
pelvis provided on March 12, 2023. 
 
You asked the Plan to pay for the CT scan. You say that the service was billed correctly and should be paid. 
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 K92.2 has an Excludes1 note in relation to K57.30. This means that the 
two diagnosis codes cannot be reported together. Based on this information, we decided that the Medicare 
billing rules for the CT scan have not been met. Therefore, we decided that the Plan does not have to pay for 
the computed tomography (CT scan) of the abdomen and pelvis provided on March 12, 2023.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to reduce the copayment for a cystourethroscopy procedure provided 
on August 08, 2023. 
 
You asked the Plan to reduce the copayment for a cystourethroscopy procedure. You say that you only paid for 
an office visit copayment for this service in the past. 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 $295 
copayment for outpatient surgery, including services provided at ambulatory surgical centers. 
 
You have been asked to pay a $295 copayment for a cystourethroscopy procedure. This item/service falls within the outpatient surgery, including services provided at ambulatory surgical centers benefit category. This 
means that you have been asked to pay the correct amount based on your contract with the Plan. This cost 
sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that 
the Plan does not have to reduce the copayment for a cystourethroscopy procedure provided on August 08, 
2023.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an ultrasound provided on August 25, 
2023. 
 
You asked the Plan to waive the copayment for an ultrasound. You say that you want to appeal the amount 
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 $100 
copayment for outpatient diagnostic tests and therapeutic services and supplies. 
 
You have been asked to pay a $100 copayment for an ultrasound. 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 $47.62. Therefore, we decided that the Plan does not have to waive the copayment 
for an ultrasound provided on August 25, 2023.
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to hold harmless for the telehealth visit provided on August 3, 2022. 
 
You asked the Plan to hold harmless for the visit. You say that this provider is in-network. The Plan denied 
your request. The Plan says that this is a duplicate claim. 
 
Medicare rules say that a contract provider is an agent of the plan. Services and referrals given by a contract 
provider are considered approved by the plan unless notice is provided that the services will not be covered. 
The Plan follows these rules. 
 
You were provided the visit by a contract provider. The Plan argues that this is a duplicate claim, which you 
should not be held liable for when billed by a contract provider. The file does not show that the Plan provided 
notice that the visit would not be covered. Under Medicare rules, this means the visit is considered approved by 
the Plan. Therefore, we decided that the Plan has to hold harmless for the telehealth visit provided on August 3, 
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: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the electrocardiogram (ECG) provided on August 15, 2023. 
 
You asked the Plan to pay for the ECG. You say that the service was billed correctly and should be paid. The 
Plan denied your request. The Plan says the claim is a duplicate of a previous claim billed by the same 
provider. 
 
In this case, the CPT Code Manual definition of code 93010 is Electrocardiogram, routine ECG with at least 12 
leads; interpretation and report only. 
 
We find that CPT code 93010-XU 76 is not supported in the medical record. Specifically, the use of the -76 
modifier is not supported because the documentation only showed that one ECG report was done for the day. 
Therefore, code 93010-XU 76 is not supported. Based on this information, we decided that Medicare rules for 
coverage of the ECG have not been met. Therefore, we decided that the Plan does not have to pay for the 
electrocardiogram (ECG) provided on August 15, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a temporary wheelchair ramp. 
 
You asked the Plan to pre-approve a temporary wheelchair ramp. You say that you are temporarily wheelchair-
bound and need this ramp to get into and out of your home.  You stated that you are non-weight bearing for 7 
weeks due to a leg fracture. You said that without this ramp you are homebound. The Plan denied your request. 
The Plan says this item is not a covered benefit. 
 
The Plan must follow Medicare rules. The rules state that for equipment to be covered, it must be appropriate 
and needed for use inside the home. The item at issue in this appeal is not for use inside of the home. Although 
this item may be helpful, neither Medicare nor the Plan covers equipment for use outside the home. Therefore, 
we decided that the Plan does not have to pre-approve a temporary wheelchair ramp.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to provide coverage for outpatient mental health counseling services to 
be provided by an out-of-network provider. 
 
You asked the Plan to provide coverage for outpatient mental health counseling services to be provided by an 
out-of-network provider. You say that you have shown improvements in your mood, coping skills, and 
communication and that you are out of bed more days and reconnecting with your hobbies. You say that you 
have developed a trusting relationship with your therapist and feel that a change in treatment or therapist could intensify your symptoms and delay your healing process. The Plan denied your request. The Plan says you have 
been attending weekly out-of-network counseling services for the last twelve months with minimal 
improvement. The out-of-network licensed clinical social worker (LCSW) has been unsuccessful in assisting 
you to confront your problems and have you set goals. 
 
The Plan must follow Medicare rules. Medicare rules say that PACE plans must cover all services determined 
necessary by the IDT to improve and maintain the enrollee's overall health status. 
 
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 provide coverage for outpatient mental health 
counseling services to be provided by an out-of-network provider. Our reviewer says that the requested 
outpatient mental health counseling services to be provided by an out-of-network provider is not considered 
medically reasonable and necessary. Our physician reviewer found that based on documentation provided, you 
are seeking treatment for continued management of mental health illness and issues related to trauma. You can 
receive care from a provider who is in-network and who has regional expertise in the treatment of childhood 
and adult trauma. The provided records show that you do not require immediate emergency treatment based on 
the documentation by an out-of-network provider. Based on the documentation provided it is assumed you can 
be treated by an in-network provider for treatment services. Utilization of an in-network provider assures a 
credentialed and clinically maintained individual assured by the medical provider to a specified standard of 
care. The Plan has agreed to pre-approved continued care with the out-of-network provider for two (2) visits 
per month for three (3) months and one (1) visit per month for five (5) months so that you can transition to 
in-network treatment. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of outpatient mental health counseling services to be provided by an out-of-
network provider have not been met. Therefore, we decided that the Plan does not have to provide coverage for 
outpatient mental health counseling services to be provided by an out-of-network provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99232 billed for date of service February 22, 
2023.  
 
You asked the Plan to pay for procedure code 99232. You say that you disagree with the denial. The Plan 
denied your request. The Plan says payment for code 99232 is bundled into payment for code 99233. 
 
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 99232 
is a column two code to column one code 99233 with a modifier indicator of 0. The column two 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 99232 billed for date of service February 22, 
2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a combination sit to stand frame/table system, any size 
including pediatric, with seat lift feature, with or without wheels (E0637). 
 
You asked the Plan to pre-approve a combination sit to stand frame/table system. You say that you disagree 
with the denial. The Plan denied your request. The Plan says this item is not covered by Medicare or the Plan. 
 
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 combination sit to stand frame/table system, any size 
including pediatric, with seat lift feature, with or without wheels (E0637).