Persius/hicric huggingface dataset:
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to approve additional routine transportation trips. 
 
You asked the Plan to approve these services. You say that you need more trips to radiation treatment. The Plan 
denied your request. The Plan says you have exhausted the benefit 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 48 one-way 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 approve additional routine transportation trips.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a home or residence visit and advance care planning 
provided from January 21, 2023, to March 18, 2023. 
 
You asked the Plan to pay for a home or residence visit and advance care planning. You say that the services 
were medically necessary. The Plan denied your request. The Plan says the Plan requires utilization of network 
providers when possible and available and requires authorization for certain services. No medical necessity for 
an out-of-network provider such as an urgent or an emergent situation that has been documented.  
 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 did not pre-approve the 
services at issue. We found no exception that would require the Plan to pay for these services. Therefore, we 
decided that the Plan does not have to pay for a home or residence visit and advance care planning provided 
from January 21, 2023, to March 18, 2023.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to pay for hospital care (99222) provided on March 7, 2023. 
 
You asked the Plan to pay for the hospital care. You say that this service was medically necessary. The Plan 
denied your request. The Plan says the claim cannot be paid as 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. 
 
We find that CPT code 99222 is not supported in the medical record. Specifically, the place of service billed 
(23- emergency room) is not a valid place of service for the code billed. Based on this information, we decided 
that Medicare rules for coverage of the hospital care have not been met. Therefore, we decided that the Plan 
does not have to pay for hospital care (99222) provided on March 7, 2023.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home health services provided from June 15, 2022, to 
July 14, 2022. 
 
You asked the Plan to pay for the home health services as billed. 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 follows Medicare rules. The rules say that if a home health (HH) claim is for a period of care in which 
there are no skilled HH visits in the billing period, but a policy exception that allows billing for covered 
services is documented at the HHA (home health agency), the HHA enters condition code 54. The claim in this 
case does not have any skilled home heath visits billed and condition code 54 was not included. Therefore, we 
decided that the Plan does not have to pay for the home health services provided from June 15, 2022, to July 
14, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for initial hospital care (procedure code 99223) rendered on 
February 12, 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 Current Procedural Terminology (CPT) code 99223 (1 Unit) 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. 
 
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 documentation supports an 
appropriate exam, but not an appropriate history or medical decision making of high level, or that 75 minutes 
or more were spent on the service.  
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 initial hospital care (procedure code 99223) rendered on February 12, 2023.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the emergency room services provided on March 23, 2023. 
 
You asked the Plan to pay for the emergency room services. You say that you would like the Plan to reconsider 
their denial of payment. The Plan denied your request. The Plan says your facility is not a valid Medicare 
provider and you have provided no evidence that you can bill Medicare. 
 
The Plan must follow Medicare rules. Medicare rules say that generally, licensed independent freestanding 
emergency departments (EDs) cannot bill Medicare. However, during the COVID-19 Public Health 
Emergency, these providers can become temporary Medicare providers if they meet certain criteria. 
 
In this case, there is no evidence that your facility meets any of the criteria listed above to receive Medicare 
payment. There is no evidence that your facility is affiliated with a hospital, and you have provided no 
evidence that you have completed the temporary enrollment process to become a Medicare hospital. As a 
result, payment to your facility cannot be made. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the emergency room services have not been met. Therefore, we decided that the Plan does not have 
to pay for the emergency room services provided on March 23, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ultraviolet light therapy system (E0691) provided on 
March 6, 2023. 
 
You asked the Plan to pay for the ultraviolet light therapy system. You say that you are appealing the denial 
with supporting documentation. The Plan denied your request. The Plan says the coverage criteria has not been 
met. 
 
The Plan must follow Medicare rules. Medicare rules say that ultraviolet cabinets are covered for selected 
patients with generalized intractable psoriasis. 
  
We looked at the file and Medicare rules. The medical records do not show documentation of a diagnosis or 
treatment for psoriasis. Based on this information, we decided that Medicare rules for coverage of the 
ultraviolet light therapy system have not been met. Therefore, we decided that the Plan does not have to pay for 
the ultraviolet light therapy system (E0691) provided on March 6, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the lab testing provided on May 24, 2023, billed with codes 
87486, 87498, 87502, 87503, 87581, 87634, 87635, 87798, & 87801. 
 
You asked the Plan to pay for the lab testing billed. You say that the services were medically necessary. The 
Plan denied your request. The Plan says panel testing should be billed using one CPT code on the claim. 
 
The Plan must follow Medicare rules. The rules say that if one laboratory procedure evaluates multiple genes 
using a next generation sequencing (NGS) procedure, the laboratory shall report only one unit of service of one 
genomic sequencing procedure, molecular multianalyte assay, multianalyte assay with algorithmic analysis, or 
proprietary laboratory analysis code. 
 We looked at the file and Medicare rules. This was a lab panel that was not billed with a single panel code as 
required. Multiple unbundled codes were billed for a single panel. Based on this information, we decided that 
Medicare rules for coverage of the lab testing billed have not been met. Therefore, we decided that the Plan 
does not have to pay for the lab testing provided on May 24, 2023, billed with codes 87486, 87498, 87502, 
87503, 87581, 87634, 87635, 87798, & 87801.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 96365, 96366, 96521, and J1817 provided 
on March 23, 2023. 
 
You asked the Plan to pay for procedure codes 96365, 96366, 96521, and J1817. 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. 
 
The Plan must follow Medicare rules. Medicare rules say that OIVIT is not covered.  
 
The records indicate that the services at issue in this case were for the purpose of outpatient intravenous insulin therapy. 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 96365, 96366, 96521, and 
J1817 provided on March 23, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a pneumatic compression device (E0675) provided 
November 23, 2022, to December 13, 2022. 
 
You asked the Plan to pay for a pneumatic compression device. You say that the enrollee was treated for post-
surgical edema and inflammation and post-surgical lymphedema. The Plan denied your request. The Plan says 
a pneumatic compression device is not covered by Medicare to prevent deep vein thrombosis during and/or 
following surgery. 
 
The Plan follows Medicare rules. The rules state that a PCD that provides intermittent limb compression for the 
purpose of prevention of venous thromboembolism (E0676) is a preventive service. The rules also say that a PCD coded as E0675 to treat peripheral arterial disease is not eligible for reimbursement. 
 
We looked at the file and Medicare rules. Based on this information we decided that Medicare rules for 
coverage of the PCD have not been met. Specifically, this item is not a covered benefit of Medicare or the Plan. 
PCDs are not covered for preventions of venous thromboembolism nor for treatment of peripheral artery 
disease, regardless of how they are billed on the claim. Therefore, we decided that the Plan does not have to 
pay for a pneumatic compression device (E0675) provided November 23, 2022, to December 13, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the dental services. 
 
You asked the Plan to pre-approve the dental services. You say that the services requested are medically 
necessary.  The Plan denied your request. The Plan says the services requested are not covered benefits. 
 
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, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve the 
dental services.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a referral to an out-of-network radiation oncologist. 
 
You asked the Plan to pre-approve these services. You say that the doctor is close to your home. The Plan 
denied your request. The Plan says the services are available from network providers. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pre-approve care from out-of-network providers only in cases involving 
emergencies, out of area urgent care and care that cannot be provided by network providers. 
 
The requested provider in this case is not a network provider with the Plan. The Plan has network providers 
available who can provide the items/services at issue in this appeal. We found no exception that would require the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve 
a referral to an out-of-network radiation oncologist.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home health services provided from June 18, 2022, to 
July 17, 2022. 
 
You asked the Plan to pay for the home health services as billed. You say that you have submitted the required 
NOA multiple times. The Plan denied your request. The Plan says the claim has not been billed with the correct 
admission date. 
 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 June 18, 2022, to July 
17, 2022.
Appeal type: Hospice
Decision: Unfavorable

 
We decided that the Plan does not have to pay for subsequent hospital care provided on June 29, 2022. 
 
You asked the Plan to pay for the subsequent hospital 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. Original Medicare is responsible for payment for services until the first day of the month after the 
hospice election has been revoked or terminated. The enrollee ended Medicare Hospice benefits on June 26, 2022. The services in question were provided before 
the end of that month. Therefore, we decided that the Plan does not have to pay for subsequent hospital care 
provided on June 29, 2022.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Orencia. 
 
You asked the Plan to pre-approve Orencia. You say that the request for Orencia is medically necessary for the 
enrollee. The Plan denied your request. The Plan says the information provided does not show that the 
requirements for Orencia have been met. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for a drug or biological only if it is safe 
and effective and otherwise reasonable and 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 Orencia. Our reviewer says that the 
requested service cannot be recommended. Our physician reviewer found the record does not indicate there is 
no active infections, including clinically important localized infections; the enrollee is not receiving a tumor 
necrosis factor (TNF) antagonist, Janus kinase (JAK) inhibitor, or other biologic therapy; the enrollee will not 
receive any live vaccines; and when it is known whether the medication is being used in combination with 
Disease-modifying antirheumatic drugs (DMARDs) or as monotherapy. The documentation does not support 
that the Orencia is medically reasonable and necessary for the enrollee. Also, the documentation does not 
support that the Orencia is safe and effective for the enrollee. 
  We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Orencia have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Orencia.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a cardiology office visit provided on March 25, 2023. 
 
You asked the Plan to pay for the cardiology office visit. You say that the services were medically necessary. 
The Plan denied your request. The Plan says the out-of-network office visit was not medically necessary. 
 
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 did not pre-approve the 
services at issue. We found no exception that would require the Plan to pay for these services. Therefore, we 
decided that the Plan does not have to pay for a cardiology office visit provided on March 25, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for medical services provided on March 9, 2023, and March 10, 
2023. 
 
You asked the Plan to pay for the medical services. You say that the diagnosis billed is consistent with the 
procedure billed. 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 J96.01 has an Excludes1 note in relation to R09.02. 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 services have not been met. Therefore, we decided that the Plan does not have to 
pay for medical services provided on March 9, 2023, and March 10, 2023.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to reimburse you for a psychiatric diagnostic evaluation provided on 
March 7, 2023. 
 
You asked the Plan to reimburse you for the psychiatric diagnostic evaluation. You say that this service was 
medically necessary. The Plan denied your request. The Plan says this provider does not accept Medicare 
assignment and 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 provided on March 7, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for initial hospital care (procedure code 99223) rendered on 
January 5, 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 the documents do not support this level of care. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
We asked our coder to carefully review the case file and apply the relevant Medicare rules to determine if the 
Plan was correct in denying the request to pay for the services. Our reviewer says that the services at issue in 
this case were not supported by the medical records. Our reviewer found that the documentation supports an 
appropriate exam, but not an appropriate history or medical decision making of high level, or that 75 minutes 
or more were spent on the service.  
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 initial hospital care (procedure code 99223) rendered on January 5, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a knee orthosis (L1843, L2397) rendered on September 8, 
2022. 
 
You asked the Plan to pay for the services. You say that this was medically necessary. The Plan denied your 
request. The Plan says the records do not show knee instability, or recent knee injury/surgery. 
 
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 
services at issue in this case were not medically reasonable or necessary. Our physician reviewer found that in 
this case, the record indicates that the enrollee has osteoarthritis of the knee. The record provided does not 
document recent injury to or a surgical procedure on the knee. The record provided does not document knee 
instability must be documented by examination of the beneficiary and objective description of joint laxity. 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 a knee orthosis (L1843, L2397) rendered on September 8, 2022.