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

 
We decided that the Plan does not have to pay for practitioner services provided on March 21, 2023, billed with 
procedure codes 99490 and 99439. 
 
You asked the Plan to pay for the practitioner services provided. You say that the claim was billed correctly 
and should be paid. The Plan denied your request. The Plan says the diagnosis is inconsistent with the 
procedure. 
 
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 codes 99490 and 99439 is chronic care management services 
with the following required elements: multiple (two or more) chronic conditions expected to last at least 12 
months, or until the death of the patient, chronic conditions that place the patient at significant risk of death, 
acute exacerbation/decompensation, or functional decline, comprehensive care plan established, implemented, revised, or monitored; first 20 minutes of clinical staff time directed by a physician or other qualified health 
care professional, per calendar month and chronic care management services with the following required 
elements: multiple (two or more) chronic conditions expected to last at least 12 months, or until the death of the 
patient, chronic conditions that place the patient at significant risk of death, acute 
exacerbation/decompensation, or functional decline, comprehensive care plan established, implemented, 
revised, or monitored; each additional 20 minutes of clinical staff time directed by a physician or other 
qualified health care professional, per calendar month (List separately in addition to code for primary 
procedure). 
 
We find that CPT codes 99490 and 99439 are not supported in the medical record. Specifically, this claim was 
only reported with one diagnosis which does not meet required criteria for the services billed. 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 March 21, 
2023, billed with procedure codes 99490 and 99439.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for evaluation and management services (procedure code 99213) 
rendered on January 23, 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 records do not support the services billed. 
 The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
In this case, the CPT Code Manual definition of code 99213 is "Office or other outpatient visit for the 
evaluation and management of an established patient, which requires a medically appropriate history and/or 
examination and low level of medical decision making. When using time for code selection, 20-29 minutes of 
total time is spent on the date of the encounter." 
 
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 records do not support 20-29 
minutes of total time was spent on evaluation and management. Additionally, there is no evidence that CPT 
99213 was separately identifiable from the endoscopy.  
 
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 evaluation and management services (procedure code 99213) rendered on January 23, 2023.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for ambulance service, advanced life support and ground 
mileage provided on February 4, 2023. 
 
You asked the Plan to pay for  ambulance service and ground mileage. You say that the medical records 
support the need for the ambulance transport. The Plan denied your request. The Plan says there is no 
documentation in the clinical record documenting any reason required services were not available or could not 
be utilized to treat the enrollee's medical condition.  
 
Medicare pays for ambulance services only when an emergency exists or when other means of transport would 
endanger the patients health. The Plan follows the same rules.  
 
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  ambulance service and ground mileage. Our 
reviewer says that the ambulance services were not medically necessary. Our physician reviewer found the 
enrollee had no reported acute signs or symptoms at time of transport and their slurred speech was chronic. The 
documentation does not support that the enrollee needed the expertise, services and lifesaving and life-
sustaining equipment that only a fully equipped ambulance can provide for safe transport. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of  ambulance service and ground mileage  have not been met. Therefore, we 
decided that the Plan does not have to pay for ambulance service, advanced life support and ground mileage 
provided on February 4, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for evaluation and management (E&M) services (procedure code 
99222) rendered on April 1, 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 records do not support the services billed. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 In this case, the CPT Code Manual definition of code 99222 is "Initial hospital inpatient or observation care, 
per day, for the evaluation and management of a patient, which requires a medically appropriate history and/or 
examination and moderate level of medical decision making. When using total time on the date of the 
encounter for code selection, 55 minutes must be met or exceeded." 
 
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 only the surgical note was 
provided and no prior pre-operative note helping to decide whether surgery was indicated or not. The records 
do not support a medically appropriate history or examination in a separate encounter, nor moderate medical 
decision making or time spent. The records do not support that this E&M service was done during the pre-
operative period.  
 
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 evaluation and management (E&M) services (procedure code 99222) rendered on April 1, 
2023.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 72170 billed for date of service March 23, 
2023. 
 You asked the Plan to pay for procedure code 72170. You say that 72170 and 73501 should be paid as billed 
because they were two separately performed medically necessary procedures. The Plan denied your request. 
The Plan says payment for code 72170 is bundled into payment for code 73501. 
 
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 72170 
is a column II code to column I code 73501. This claim has not been billed with an appropriate modifier to 
bypass the edit. 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 72170 billed for date of service March 23, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for nutritional supplies (B4199, B4224, B4220) provided on 
April 1, 2023 to April 6, 2023. 
 
You asked the Plan to pay for the nutritional supplies. You say that these items were medically necessary. 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 which support medical necessity for the supplies provided 
in this case. The physician order does not specify these items for the date of service billed. 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 nutritional supplies (B4199, B4224, B4220) provided on April 1, 
2023 to April 6, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the OIVIT services provided on May 4, 2023. 
 
You asked the Plan to pay for the OIVIT services. You say that you are appealing the denial with supporting 
documentation. The Plan denied your request. The Plan says the billed services are not supported. 
 
The Plan must follow Medicare rules. Medicare rules say that OIVIT is not reasonable and necessary for any 
indication. 
 
We looked at the file and Medicare rules. Per Medicare, OIVIT services are not covered. Based on this 
information, we decided that Medicare rules for coverage of the OIVIT services have not been met. Therefore, 
we decided that the Plan does not have to pay for the OIVIT services provided on May 4, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the drug testing provided on February 17, 2023. 
 
You asked the Plan to pay for the drug testing. You say that you were unable to request authorization before 
services were provided. 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 drug testing 
provided on February 17, 2023.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an emergency room (ER) visit provided on 
April 09, 2023. 
 
You asked the Plan to waive the copayment for an emergency room (ER) visit. You say that you are on a fixed 
income and are unable to afford the copayment applied. 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 $95 
copayment for emergency care. 
 
You have been asked to pay a $95 copayment for an emergency room (ER) visit. 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. The total you owe is $76.11, which is less than the standard copayment for an ER visit. Therefore, 
we decided that the Plan does not have to waive the copayment for an emergency room (ER) visit provided on 
April 09, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the MyoPro Motion G orthotic device (L8702). 
 
You asked the Plan to pre-approve the orthotic device. You say that the enrollee was referred by their doctor 
for myoelectric restoration using the MyoPro Motion G. The Plan denied your request. The Plan says this item 
is considered experimental and investigational. There is insufficient evidence of its effectiveness in those with 
stroke and hemiparesis. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the orthotic device have not been met. Therefore, we decided that the Plan does not have to pre-
approve the MyoPro Motion G orthotic device (L8702).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit provided on January 23, 2023, by an out-of-
network (OON) provider.  
 
You asked the Plan to pay for an office visit. You say that you are appealing the denied claim. The Plan denied 
your request. The Plan says this provider is out-of-network and authorization was not obtained. 
 
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 an office visit provided on January 23, 2023, by an 
out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the cost share for an office visit on March 02, 2022.  
 
You asked the Plan to waive the cost share for an office visit. 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 20% 
coinsurance at primary care provider's (PCP) office or specialist's office. Covered drugs include drugs that 
usually aren't self-administered by the patient and are injected or infused while you are getting physician, 
hospital outpatient, or ambulatory surgical center services. The provider billed in the amount of $318.36 and 
the allowed amount is $113.10. There is a $110.84 and a $2.26 coinsurance. $110.84 + $2.26 = $113.10. 
Therefore, results in the total cost sharing amount of $113.10. 
 
You have been asked to pay a $113.10 cost share for an office visit. This item/service falls within the Medicare 
Part B prescription drugs 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 cost share for an office 
visit on March 02, 2022.
Appeal type: Surgery
Decision: Favorable

 
We decided that the Plan has to pre-approve percutaneous imaged-guided lumbar decompression (PILD) 
procedure (0275T). 
 
You asked the Plan to pre-approve a PILD procedure. You say that this is medically necessary. The Plan 
denied your request. The Plan says that the documentation provided does not indicate Medicare clinical trial 
NCT03072927 enrollment and therefore the initial denial was appropriate and therefore upheld on appeal. 
 
The Plan must follow Medicare rules.  
 
We looked at the file and Medicare rules. We find that the study referenced above does meet CED criteria. No 
other valid rationale was provided to support this denial. Based on this information, we decided that Medicare 
rules for coverage of a PILD procedure have been met. Therefore, we decided that the Plan has to pre-approve 
percutaneous imaged-guided lumbar decompression (PILD) procedure (0275T).  
 
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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a pneumatic compression device (E0675) provided August 2, 
2022, to August 19, 2022. 
 
You asked the Plan to pay for a pneumatic compression device. You say that you believe these services were 
medically necessary. The Plan denied your request. The Plan says a PCD coded as E0675 to treat PAD is not 
eligible for reimbursement 
 
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 August 2, 2022, to August 19, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit provided on January 16, 2023, by an out-of-
network (OON) provider.  
 
You asked the Plan to pay for an office visit. You say that you are appealing the denied claim. The Plan denied 
your request. The Plan says this provider is out-of-network and authorization was not obtained. 
 
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 an office visit provided on January 16, 2023, by an 
out-of-network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve endosteal implants (D6010 x 2), semi-precision 
abutments (D6191 x 2) and semi-precision attachments (D6192 x 2). 
 
You asked the Plan to pre-approve the dental services. You say that you are appealing the denial. The Plan 
denied your request. The Plan says some services are not covered under your dental plan and medical necessity 
was not established for others. 
 
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. 
 
The Plan must follow Medicare rules. Medicare rules say that for Medicare to consider coverage and payment 
for any item or service, the information submitted by the supplier or provider must corroborate the 
documentation in the beneficiary's medical documentation and confirm that Medicare coverage criteria have 
been met. 
 
We looked at the file and Medicare rules. Based on this information, we decided that there is insufficient 
information in the record to determine if Medicare rules for coverage of endosteal implants (D6010 x 2), semi-
precision abutments (D6191 x 2). No records or other documentation showing the requested services are 
medically necessary have been submitted. Additionally, semi-precision attachments (D6192 x 2) are not 
covered under any circumstance. Therefore, we decided that the Plan does not have to pre-approve endosteal 
implants (D6010 x 2), semi-precision abutments (D6191 x 2) and semi-precision attachments (D6192 x 2).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a pneumatic compression device (E0652) and segmental 
pneumatic appliances (E0667, E0656). 
 
You asked the Plan to pre-approve a pneumatic compression device and appliances. You say that the enrollee 
needs knee replacement, but it cannot be done due to the swelling being so severe. The Plan denied your 
request. The Plan says the enrollee does not meet the LCD criteria for an advanced lymphedema pump as there 
is no failed four-week trial of a basic pneumatic compression device of either E0650 or E0651. 
 
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.  Therefore, we decided that the Plan does not have to pre-approve a pneumatic compression device 
(E0652) and segmental pneumatic appliances (E0667, E0656).