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

 
We decided that the Plan does not have to pay for a dermatology visit provided on November 29, 2022. 
 
You asked the Plan to pay for a dermatology visit. You say that this was medically necessary and should be 
paid. 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 a dermatology visit 
provided on November 29, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a mobile wrist x-ray provided on June 27, 2023. 
 
You asked the Plan to pay for a mobile wrist x-ray. You say that please review the medical documents and 
reconsider. 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 a mobile wrist x-ray 
provided on June 27, 2023.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for inpatient hospital services provided on March 4, 2023, to 
March 9, 2023, at the Diagnosis Related Group (DRG) originally billed. 
 
  You asked the Plan to pay for the inpatient hospital services at the DRG originally billed. You say that Sepsis 
unspecified organism and severe sepsis, without septic shock, are the correct principal and secondary 
diagnoses. The Plan denied your request. The Plan says the Payment Integrity post-service post-pay clinical 
validation audit shows that the provider has reported inpatient hospital services with the incorrect DRG. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report inpatient hospital services with the appropriate DRG, which is based, in part, on the 
reported principal and secondary diagnosis codes.   
 
In this case, you billed the inpatient services provided with principal diagnosis code, A41.9, defined as sepsis 
unspecified organism and secondary diagnosis code, R65.20, defined as severe sepsis without septic shock. 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 inpatient hospital services at the DRG 
originally billed. Our reviewer says that the services at issue in this case were not supported by the medical 
records. Our physician reviewer found sepsis-3 criteria was not met as there was insufficient evidence of organ 
failure directly related to a dysregulated response to systemic infection as required. Therefore, the codes, A41.9 
(sepsis) and R65.20 (severe sepsis) are not sufficiently supported for this admission. DRG 177 is more 
appropriate.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided the 
medical records do not substantiate the DRG as billed. Therefore, we decided that the Plan does not have to pay 
for inpatient hospital services provided on March 4, 2023, to March 9, 2023, at the Diagnosis Related Group 
(DRG) originally billed.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a knee scooter (E0118). 
 
You asked the Plan to pre-approve a knee scooter. You say that the requested item is a necessity for your care. 
The Plan denied your request. The Plan says the requested item is not a covered benefit. 
 
The Plan must follow Medicare rules. Medicare rules say that that there is insufficient published clinical 
literature demonstrating safety and effectiveness in the Medicare population to establish the medical necessity 
for a crutch substitute. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of a knee scooter have not been met. Specifically, this item is not a covered benefit of Medicare or the 
Plan. Therefore, we decided that the Plan does not have to pre-approve a knee scooter (E0118).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve nutritional supplement (B4152). 
 
You asked the Plan to pre-approve nutritional supplement. You say that the requested item is a necessity for 
your care. The Plan denied your request. The Plan says the requested item is not a covered benefit as 
administered. 
 
The Plan must follow Medicare rules. Medicare rules say that orally administered enteral nutrition products, 
related supplies and equipment will be denied as non-covered. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of nutritional supplement have not been met. Specifically, the requested item is an enteral nutrition 
product. In this case, the product is intended for oral administration. Therefore, we decided that the Plan does 
not have to pre-approve nutritional supplement (B4152).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the office visit to be provided by an out-of-network 
(OON) provider.  
 
You asked the Plan to pre-approve the office visit. You say that you are asking for your claim to be 
reevaluated. The Plan denied your request. The Plan says the enrollee must receive their care from a network 
provider (for more information about this, see Section 2 in Chapter 3). In most cases, care the enrollee receives 
from an out-of-network provider (a provider who is not part of the plans network) will not be 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 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 
the office visit to be provided by an out-of-network (OON) provider.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve psychotherapy. 
 
You asked the Plan to pre-approve the psychotherapy. You say that this provider is the nearest location that 
provided the service The Plan denied your request. The Plan says your request for services from a licensed 
professional counselor (LPC) is not medically necessary because the services of a LPC are not Medicare 
covered services. 
 
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 pre-approve psychotherapy.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a pneumatic compression device (E0652) and related 
supplies (E0667). 
 
You asked the Plan to pre-approve a pneumatic compression device and related supplies. You say that the 
requested item is a medical necessity for the enrollee. The Plan denied your request. The Plan says rules for 
coverage for a PCD coded as E0652 have not been met. 
 
The Plan follows Medicare rules. The rules state that a PCD coded as E0652 is covered for the treatment of 
lymphedema extending onto the chest, trunk and/or abdomen after a four-week trial of conservative therapy 
demonstrating failed response to treatment with an E0650 or E0651. At least four weeks of regular, daily, 
multiple-hour home usage of the E0650 or E0651 is required. 
 
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, the record does not show that the enrollee had at least 
four weeks of regular, daily, multiple-hour home usage of the E0650 or E0651 after careful, in-person fitting, 
training and supervision by a technician who is skilled in and who regularly and successfully uses the appliance 
provided. Because the base item E0652 is not covered, the related supplies E0667 are also not covered. 
Therefore, we decided that the Plan does not have to pre-approve a pneumatic compression device (E0652) and 
related supplies (E0667).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the evaluation and management services described by codes 
99205 and G2212 billed for date of service July 10, 2023. 
 
You asked the Plan to pay for 99205 and G2212. You say that 99205 and G2212 should be paid as billed 
because July 10, 2023, was the enrollee's first encounter for palliative care. The Plan denied your request. The 
Plan says 99205 is denied because it does not appropriately describe the services received by the enrollee. 
G2212 is denied because it was billed without an appropriate primary procedure. 
 
The Plan must follow Medicare rules. Medicare rules say that the phrase "new patient" is interpreted to mean 
someone who has not received any professional services such as E&M services or other face-to-face services 
from the physican or physican group practice (same physician specialty) within the previous 3 years. The rules 
also say that an add-on code is eligible for payment only if it is reported with an appropriate primary procedure 
performed by the same practitioner. 
 
We looked at the file and Medicare rules. Regarding code 99205, we confirmed that the case file contains proof 
that this enrollee received evaluation and management services on July 2, 2023, July 3, 2023, and July 4, 2023, 
from a provider of the same group practice and same specialty as the rendering provider for the date of service 
in question, July 10, 2023. July 2, 3, and 4, 2023, are within the 3 years prior to July 10, 2023. As such, this 
enrollee would not be considered new to the group practice on July 10, 2023. This means code 99205, 
indicating the enrollee has not received professional services from the physician group practice within the last 3 
years, is not supported. Regarding code G2212, we confirmed this is an add-on code. Per Medicare rules, an 
add-on code is only eligible for payment if it is reported with an appropriate primary procedure. In this case, 
the primary procedure, code 99205 is denied, therefore, G2212 is also denied. Based on this information, we 
decided that Medicare rules for coverage of 99205 and G2212 have not been met. Therefore, we decided that 
the Plan does not have to pay for the evaluation and management services described by codes 99205 and 
G2212 billed for date of service July 10, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an office visit to be provided by an OON provider.  
 
You asked the Plan to pre-approve an office visit. You say that you are requesting reconsideration of the denied 
service. The Plan denied your request. The Plan says the service was not approved. 
 
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 service at issue in this appeal. We found no exception that would require the 
Plan to pre-approve the service. Therefore, we decided that the Plan does not have to pre-approve an office 
visit to be provided by an OON provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve repairs for a manual wheelchair. 
 
You asked the Plan to pre-approve repairs for a manual wheelchair. You say that the manual wheelchair is not 
a backup wheelchair and is the only wheelchair you currently use as you do not use your power wheelchair at 
this time as you are not able to transport the power wheelchair for use outside the home. You say that you also 
do not use the power wheelchair at home and only use your manual wheelchair that needs the repair. The Plan 
denied your request. The Plan says payment is made for only one wheelchair at a time and backup chairs are 
denied as not reasonable and necessary. The Plan says you received your power wheelchair on September 12, 
2022. 
 
The Plan must follow Medicare rules. The rules say Medicare covers DME only when it is reasonable and 
necessary. If DME serves the same purpose as equipment already available to an enrollee, it is not considered 
reasonable and necessary. 
 
The file shows that you have a power wheelchair. The power wheelchair serves the same purpose as your 
manual wheelchair. Since a duplicate DME would not be covered, repairs for a duplicate DME are not covered. 
Therefore, we decided that the Plan does not have to pre-approve repairs for a manual wheelchair.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the preventive medicine reevaluation provided on August 11, 
2023. 
 
You asked the Plan to pay for the preventive medicine reevaluation. You say that you are requesting 
reconsideration of the denied claim. 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 preventive medicine 
reevaluation provided on August 11, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve image guided radiation therapy (IGRT). 
 
You asked the Plan to pre-approve image guided radiation therapy (IGRT). You say that you are requesting 
reconsideration for the denied claim. The Plan denied your request. The Plan says it is not medically necessary. 
 
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 image guided radiation therapy (IGRT). 
Our reviewer says that the requested items/services are not considered medically reasonable and necessary in 
this case. Our physician reviewer found that when treating skin cancers, there is generally not a need for IGRT 
unless deep structures are being treated.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of image guided radiation therapy (IGRT) have not been met. Therefore, we 
decided that the Plan does not have to pre-approve image guided radiation therapy (IGRT).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit provided on July 17, 2023. 
 
You asked the Plan to pay for an office visit. You say that you are requesting reconsideration of the denied 
claim. 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 provided 
on July 17, 2023.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an interspinous decompression spacer procedure. 
 
You asked the Plan to pre-approve the procedure. You say that this procedure is necessary due to the failure of 
conservative treatments to address pain and restore function. The Plan denied your request. The Plan says 
experimental and investigational procedures are not covered. 
 
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 procedure. Our reviewer says that 
the requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found that interspinous spacers are considered experimental/investigational and are not medically 
necessary for the treatment of chronic pain. 
 We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the procedure have not been met. Therefore, we decided that the Plan does not 
have to pre-approve an interspinous decompression spacer procedure.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 88305 billed for May 5, 2023. 
 
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says the billed primary diagnosis is not appropriate. 
 
The Plan must follow Medicare rules. The rules say that claims must be billed with the most precise diagnosis 
code. 
 
We looked at the file and Medicare rules. The file shows that the services were not billed with an appropriate 
primary diagnosis code. 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 pay for procedure code 88305 
billed for May 5, 2023.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the ambulance services provided on August 
01, 2022. 
 
You asked the Plan to waive the copayment for the ambulance services. You say that you should not have to 
pay for an ambulance ride. 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 $225 
copayment for ambulance services. 
 
You have been asked to pay a $225 copayment for the ambulance services. This item/service falls within the 
ambulance services 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 ambulance 
services provided on August 01, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99231-GC billed for date of service January 
3, 2023.  
 
You asked the Plan to pay for procedure code 99231-GC. You say that the claim is billed correctly and should 
be paid. The Plan denied your request. The Plan says payment for code 99231-GC is bundled into payment for 
code 99239. 
 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 
99231-GC is a column two code to column one code 99239 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 99231-GC billed for date of 
service January 3, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the high frequency chest wall oscillation device 
(HFCWODs) (E0483). 
 
You asked the Plan to pre-approve the HFCWOD. You say that you are requesting a review of the denial of 
coverage of the Vest system. The Plan denied your request. The Plan says the enrollee does not meet the 
criteria for coverage. 
 
The Plan must follow Medicare rules. Medicare rules say that high frequency chest wall oscillation devices are 
covered only for patients with cystic fibrosis, bronchiectasis, or certain neuromuscular diseases.  
The record does not show that the enrollee has cystic fibrosis, bronchiectasis, or a covered neuromuscular 
disease. This means that the enrollee does not have a medical condition for which a high frequency chest wall 
oscillation device can be covered or paid for by Medicare. Therefore, we decided that the Plan does not have to 
pre-approve the high frequency chest wall oscillation device (HFCWODs) (E0483).