Persius/hicric huggingface dataset:
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99308 billed for date of service April 28, 
2023. 
 
You asked the Plan to pay for the billed service. You say that the documentation supports the emergency 
conditions. The Plan denied your request. The Plan says the billed code is 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 99308 is echocardiography, transthoracic, real-time with 
image documentation (2D), includes M-mode recording, when performed, follow-up or limited study. 
 
We find that CPT code 99308 is not supported in the medical record. The records do not include documentation 
of a transthoracic echocardiogram with image documentation. Based on this information, we decided that 
Medicare rules for coverage of the billed service have not been met. Therefore, we decided that the Plan does 
not have to pay for procedure code 99308 billed for date of service April 28, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for diabetic supplies provided on July 21, 2023, to August 21, 
2023. 
 
You asked the Plan to pay for diabetic supplies. You say that all of the appropriate documents have been 
provided for payment. The Plan denied your request. The Plan says the documentation requirements have not 
been met. 
 
The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when there is a valid 
physician order, proof of delivery and relevant medical records which support medical necessity.  
 
The record does not contain a valid proof of delivery. The proof of delivery provided does not have the 
enrollees signature. The record shows that the Plan made several attempts to obtain the necessary 
documentation without success. Therefore, we decided that the Plan does not have to pay for diabetic supplies 
provided on July 21, 2023, to August 21, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for practitioner services provided on February 24, 2023, to 
February 28, 2023, billed with procedure code A6219. 
 
You asked the Plan to pay for the practitioner services provided. You say that the claim is billed correctly and 
should be paid. The Plan denied your request. The Plan says the service is packaged and is not separately 
payable. 
 
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 A6219 is not supported in the medical record. Specifically, the billed code has a status 
indicator N and is not separately payable. Based on this information, we decided that Medicare rules for 
coverage of the practitioner services provided have not been met. Therefore, we decided that the Plan does not have to pay for practitioner services provided on February 24, 2023, to February 28, 2023, billed with 
procedure code A6219.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve facet joint interventions for pain management. 
 
You asked the Plan to pre-approve facet joint interventions for pain management. You say that it is medically 
necessary. The Plan denied your request. The Plan says it is not medically necessary. 
  
The Plan follows Medicare rules. Medicare rules say that facet joint interventions are covered when the criteria 
listed in the Medicare rules section is met. 
 
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 facet joint interventions for pain 
management. Our reviewer says that the service is not medically necessary. Our physician reviewer found the 
enrollee has evidence of radiculopathy. The review has determined that the enrollee does not meet the coverage 
indications for this procedure. The enrollee does not meet any of the limitations/exclusions for this request. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of facet joint interventions for pain management have not been met. Therefore, we 
decided that the Plan does not have to pre-approve facet joint interventions for pain management.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99358 billed for date of service August 4, 
2023.  
 
You asked the Plan to pay for procedure code 99358. You say that 99358 should be paid as billed because it is 
supported in the documentation. The Plan denied your request. The Plan says payment for code 99358 is 
bundled into payment for code 99214. 
 
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 99358 is a column two code to column one code 99214 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 99358 billed for date of service August 4, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code P9603 billed for date of service September 8, 
2023. 
 
You asked the Plan to pay for the billed service. You say that travel logs support the claim. The Plan denied 
your request. The Plan says no medical records were submitted. 
 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 P9603 is travel allowance one way in connection with 
medically necessary laboratory specimen collection drawn from home bound or nursing home bound patient; 
prorated miles actually travelled. 
 
We find that CPT code P9603 is not supported in the medical record. The records provided do not include 
documentation of travel for the date of service at issue. The file does show that the Plan made multiple attempts 
to obtain records for the date in question, but none was provided. Based on this information, we decided that 
Medicare rules for coverage of the billed service have not been met. Therefore, we decided that the Plan does 
not have to pay for procedure code P9603 billed for date of service September 8, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for nursing facility care provided on September 19, 2023, by an 
OON provider.  
 
You asked the Plan to pay for nursing facility care. You say that your professional services have always been 
covered under the facility authorization. The Plan denied your request. The Plan says the enrollee must receive 
their care from a network provider.  
 
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 Plan had network providers available who were capable of providing the items/services at issue in this 
appeal. (Please note, items and services received in-network are still subject to any other Medicare coverage 
rules that apply.) 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. While the Plan does provide limited coverage for services 
outside any Plan service area, these services were provided within the Plan service area. Therefore, we decided 
that the Plan does not have to pay for nursing facility care provided on September 19, 2023, by an out-of-
network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the medical eye exam and evaluation (92014) and eye 
refraction (92015) provided on May 9, 2023. 
 
You asked the Plan to pay for the medical eye exam and evaluation and eye refraction. You say that you 
booked the appointment for a routine eye exam, but when you got the bill there was a $35 copay. You also say 
that you spoke with the doctor at your latest appointment and were advised they indicated it was a routine exam 
for the May 9, 2023, date of service. The Plan denied your request. The Plan says the claim that was submitted 
indicates that the services you received on May 9, 2023, were services provided by a specialist for an 
ophthalmological medical exam to determine your refractive state 
 
Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine 
vision and eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in 
this case. 
 
 We looked at the file and the Plan's rules. The contract clearly states that you must pay a $35 copayment for 
each Medicare-covered diagnostic exam. The record shows that you were seen at this appointment for 
established Presbyopia, and this was not a routine exam. Based on this information, we decided that the Plan's 
rules for coverage of the medical eye exam and evaluation and eye refraction have not been met. Therefore, we 
decided that the Plan does not have to pay for the medical eye exam and evaluation (92014) and eye refraction 
(92015) provided on May 9, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for debridement services provided on August 11, 2023, to 
August 18, 2023. 
 
You asked the Plan to pay for debridement services. You say that this 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 Plan had network providers available who were capable of providing the items/services at issue in this 
appeal. (Please note, items and services received in-network are still subject to any other Medicare coverage 
rules that apply.) 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 debridement services provided on August 11, 2023, to August 18, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a fluid circulating cold pad with pump (E0218) provided on 
May 19, 2023, through June 13, 2023. 
 
You asked the Plan to pay for a fluid circulating cold pad with pump. You say that you are requesting 
reconsideration and have submitted medical records for review. The Plan denied your request. The Plan says 
the requested pump is not covered by the Plan. 
 
The Plan must follow Medicare rules. Medicare rules say that a fluid circulating cold pad with pump will be 
denied as not reasonable and necessary.  
 
 
 We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of a fluid circulating cold pad with pump have not been met. Specifically, the requested item is not 
covered by Medicare or the Plan. Therefore, we decided that the Plan does not have to pay for a fluid 
circulating cold pad with pump (E0218) provided on May 19, 2023, through June 13, 2023.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ambulance response and treatment, no transport provided 
on July 28, 2023. 
 
You asked the Plan to pay for the ambulance response and treatment. You say that you disagree with the denial 
for the ambulance services. The Plan denied your request. The Plan says this is not a covered service by 
Medicare. 
 
The Plan must follow Medicare rules. The rules say that Medicare does not pay for ambulance services when 
there is no transport.  
 
The ambulance company did not provide transport services on July 28, 2023. The ambulance benefit is a 
transportation benefit. When there is no transport, neither Medicare nor the Plan pays for the services provided. 
Therefore, we decided that the Plan does not have to pay for the ambulance response and treatment, no 
transport provided on July 28, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the diabetic testing supplies provided on August 14, 2023. 
 
You asked the Plan to pay for the diabetic testing supplies. You say that you disagree with the Plan's denial. 
The Plan denied your request. The Plan says the documentation requirements have not been met. 
 
The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when there is a valid 
physician order, proof of delivery and relevant medical records which support medical necessity.  
 
 The record does not contain a valid physician order for the supplies provided in this case. No physician order 
was submitted. The record shows that the Plan made several attempts to obtain the necessary documentation 
without success. Therefore, we decided that the Plan does not have to pay for the diabetic testing supplies 
provided on August 14, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the office visit provided on September 18, 2023, by an out-
of-network (OON) provider.  
 
You asked the Plan to pay for the office visit. You say that due to a short time period you were unable to get 
authorization in time. The Plan denied your request. The Plan says the services do not meet the criteria for 
approval. 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 Plan had network providers available who were capable of providing the items/services at issue in this 
appeal. (Please note, items and services received in-network are still subject to any other Medicare coverage 
rules that apply.) 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 office visit provided on September 18, 2023, by an out-of-network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for panel testing provided on October 12, 2023. 
 
You asked the Plan to pay for panel testing. You say that you are dependent on receiving patient information 
from the ordering provider. The Plan denied your request. The Plan says this claim was not billed with the 
appropriate coding. 
 
The Plan must follow Medicare rules. Medicare rules say that infectious disease pathogen identification testing 
panels must be billed with a single procedure code.  
 
We looked at the file and Medicare rules. This testing was not billed with the appropriate coding. Based on this 
information, we decided that Medicare rules for coverage of panel testing have not been met. Therefore, we 
decided that the Plan does not have to pay for panel testing provided on October 12, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay more for the eyewear purchased on July 11, 2023. 
 
You asked the Plan to pay more for the eyewear. You say that the reimbursement for the exam and refraction 
has nothing to do with your $200 reimbursement toward your glasses. You also say that you would like to 
receive the $200 owed to you. The Plan denied your request. The Plan says the Health Plan has issued the 
maximum amount for the eyewear allowance. 
 
Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine 
vision and eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in 
this case. The Plan reimburses up to $200 every year for non-Medicare covered prescription eyewear. 
 
 
 
 We looked at the file and the Plan's rules. The record shows that the Plan applied the full $200 reimbursement 
toward the eyewear purchased on July 11, 2023, and your eyewear allowance has been exhausted. The $200 
eyewear allowance was not applied to the eye exam. While the Plan did pay for an eye exam, that was a 
separate amount. Based on this information, we decided that the Plan's rules for coverage of the eyewear have 
not been met. Therefore, we decided that the Plan does not have to pay more for the eyewear purchased on July 
11, 2023.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. You say that you are requesting reconsideration of denied 
authorization. The Plan denied your request. The Plan says the coverage criteria has not been met.  
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 
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 IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found the complexity of the enrollee's nursing, medical, and rehabilitation needs do not 
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The enrollee 
has had a decline from her baseline level of function and may benefit from occupational and physical therapies 
as well as some supervision and assistance, but she does not require the intensity of therapies provided in an 
acute inpatient rehabilitation. Therefore, an acute inpatient rehabilitation admission is not medically necessary.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the supply allowance for a continuous glucose monitor 
(CGM) provided on July 2, 2023. 
 
You asked the Plan to pay for the supply allowance for a CGM. You say that you have submitted all supporting 
documentation. The Plan denied your request. The Plan says the provider is not a plan contract provider and is 
not enrolled in Medicare as a durable medical equipment supplier. 
 
The Plan must follow Medicare rules. The rules say that Medicare payment cannot be made to a provider that is 
not enrolled in the Medicare program. 
 
Review of the file and Medicare records indicates that the provider at issue is not enrolled in the Medicare 
program. Therefore, we decided that the Plan does not have to pay for the supply allowance for a continuous 
glucose monitor (CGM) provided on July 2, 2023.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for he outpatientdiagnostic cardiovascular 
(EKG) services provided on August 29, 2023. 
 
You asked the Plan to waive the copayment for he outpatientdiagnostic cardiovascular (EKG) services. You 
say that the cost share is wrong. 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 $30 
copayment for Outpatient diagnostic tests and therapeutic services and supplies. 
 
You have been asked to pay a $30 copayment for he outpatientdiagnostic cardiovascular (EKG) services. 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. Therefore, we decided that 
the Plan does not have to waive the copayment for he outpatientdiagnostic cardiovascular (EKG) services 
provided on August 29, 2023.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for he evaluation and management of a patient 
(99285) provided on September 04, 2023. 
 
You asked the Plan to waive the copayment for he evaluation and management of a patient (99285). You say 
that the cost share is wrong. 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 $90 
copayment for emergency care. 
 
You have been asked to pay a $90 copayment for he evaluation and management of a patient (99285). This 
item/service falls within the emergency care 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 he evaluation and management of a patient (99285) provided on September 04, 2023.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for ambulance treatment without transport provided on August 
14, 2023. 
 
You asked the Plan to pay for the ambulance treatment without transport. You say that you were feeling better 
after treatment and did not need to go to the hospital. The Plan denied your request. The Plan says the Medicare 
ambulance benefit is a transportation benefit and without a transport there is no payable service. 
 
The Plan must follow Medicare rules. The rules say that Medicare does not pay for ambulance services when 
there is no transport.  
 
The ambulance company did not provide transport services on August 14, 2023. The ambulance benefit is a 
transportation benefit. When there is no transport, neither Medicare nor the Plan pays for the services provided. 
Therefore, we decided that the Plan does not have to pay for ambulance treatment without transport provided 
on August 14, 2023.