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

 
We decided that the Plan does not have to pay for a pneumatic compression device (E0675) provided on March 
30, 2023 to April 26, 2023. 
 
You asked the Plan to pay for a pneumatic compression device. You say that this item was medically 
necessary. The Plan denied your request. The Plan says this is not a covered item. 
 
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 on March 30, 2023 to April 26, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 99601 and 99602 billed for date of service 
July 23, 2023. 
 
You asked the Plan to pay for procedure codes 99601 and 99602. You say that the claim is billed correctly and 
should be paid. The Plan denied your request. The Plan says the billed codes are invalid for Medicare purposes.  
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate procedure code. 
 
We find that procedure codes 99601 and 99602 have a Status Indicator of I on the Physician Fee Schedule. This means that procedure codes 99601 and 99602 are not valid for Medicare purposes. Based on this 
information, we decided that Medicare rules for coverage of procedure codes 99601 and 99602 have not been 
met. Therefore, we decided that the Plan does not have to pay for procedure codes 99601 and 99602 billed for 
date of service July 23, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a urine collection system (A6590, K1006) provided on July 
13, 2023. 
 
You asked the Plan to pay for the urine collection system. You say that this service was medically necessary. 
The Plan denied your request. The Plan says the provider is not eligible for Medicare payment. 
 
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 a urine collection system (A6590, 
K1006) provided on July 13, 2023.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to reimburse you for the individual psychotherapy visits (90837) 
provided May 2, 2023, to August 30, 2023. 
 
You asked the Plan to reimburse you for the psychotherapy visits. You say that you were reimbursed for 
services provided January 2023 to April2023 and now they are denied. Please explain why they were paid as a 
reimbursement but no longer qualify. The Plan denied your request. The Plan says the services was rendered by 
a provider type that is not eligible to participate in the Medicare program. 
 
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 reimburse you for the individual psychotherapy 
visits (90837) provided May 2, 2023, to August 30, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the wound care supplies provided on July 24, 2023. 
 
You asked the Plan to pay for the wound care supplies. 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 wound care supplies 
provided on July 24, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the office visit provided on July 06, 2023. 
 
You asked the Plan to pay for the office visit. You say that the services were medically necessary. 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 office visit provided 
on July 06, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 01922 billed for date of service February 8, 
2023. 
 You asked the Plan to pay for procedure code 01922. You say that you have included the medical records for 
approval. The Plan denied your request. The Plan says payment for code 01922 is bundled into payment for 
code 00537. 
 
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 01922 
is a column II code to column I code 00537. 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 01922 billed for date of service February 8, 
2023.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for psychotherapy visit provided on August 15, 2023. 
 
You asked the Plan to pay for psychotherapy visit. You say that you did not know you would need a referral to 
see this provider. 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 psychotherapy visit 
provided on August 15, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for codes A6446, A4450, A6213, A6197, and A6252 for date of 
service November 16, 2022. 
 
You asked the Plan to pay for codes A6446, A4450, A6213, A6197, and A6252. You say that you disagree 
with the Plan's denial. The Plan denied your request. The Plan says the services are not payable as billed. 
 The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate code. 
 
We find that codes A6446, A4450, A6213, A6197, and A6252 are not payable as billed. Specifically, these 
services were billed in the place of service 12 (home). The documentation shows that the enrollee was an 
inpatient of a hospital. Therefore, it is inappropriate to bill these items with a place of service of 12. Based on 
this information, we decided that Medicare rules for coverage of codes A6446, A4450, A6213, A6197, and 
A6252 have not been met. Therefore, we decided that the Plan does not have to pay for codes A6446, A4450, 
A6213, A6197, and A6252 for date of service November 16, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for travel allowance for laboratory specimen collection (P9603) 
billed for date of service August 16, 2023. 
 
You asked the Plan to pay for travel allowance. You say that you have reported the service at issue correctly. 
The Plan denied your request. The Plan says the provided records do not support the service 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 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 case record. Specifically, the available records do not indicate that a laboratory technician collected the specimen at issue. Based on this information, we decided that 
Medicare rules for coverage of travel allowance have not been met. Therefore, we decided that the Plan does 
not have to pay for travel allowance for laboratory specimen collection (P9603) billed for date of service 
August 16, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an out-of-network podiatry debridement 
provided on July 28, 2023. 
 
You asked the Plan to waive the copayment for an out-of-network podiatry debridement. You say that this visit 
was supposed to be a $0 copayment, not a $30 one. 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 podiatry services. 
 
You have been asked to pay a $30 copayment for an out-of-network podiatry debridement. This item/service 
falls within the podiatry 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 
an out-of-network podiatry debridement provided on July 28, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99140 billed for date of service August 29, 
2023. 
 
You asked the Plan to pay for procedure code 99140. You say that this service was medically necessary. The 
Plan denied your request. The Plan says procedure code 99140 is considered bundled and 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 procedure code. 
 
We find that procedure code 99140 has a status indicator of B on the Physician Fee Schedule. This means that 
procedure code 99140 is not separately payable. Based on this information, we decided that Medicare rules for 
coverage of procedure code 99140 have not been met. Therefore, we decided that the Plan does not have to pay 
for procedure code 99140 billed for date of service August 29, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services provided on July 11, 2023, to July 14, 
2023. 
 
You asked the Plan to pay for the laboratory services. 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 laboratory services 
provided on July 11, 2023, to July 14, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the cost share for the physical exam and an office visit on 
January 20, 2023. 
 
You asked the Plan to waive the cost share for the physical exam and 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 40% 
coinsurance for a routine physical exam each year from an out-of-network provider. You must pay a $20 
copayment for services from a primary care provider or under certain circumstances, treatment by a nurse 
practitioner, physician's assistant or other non-physician health care professional in a primary care provider's 
office (as allowed by Medicare). The provider billed in the amount of $150 and the allowed amount is $134.25. 
For the service it's $134.25 x 40% = $53.70. For both services it's $53.70 + $20 = $73.70. Therefore, results in 
the total cost sharing amount of $73.70. 
 
You have been asked to pay a $73.70 cost share for the physical exam and an office visit. This item/service 
falls within the annual routine physical exam and physician/practitioner services, including doctors office 
visits benefit category. This means that you have been asked to pay the correct amount based on your contract 
with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. 
Therefore, we decided that the Plan does not have to waive the cost share for the physical exam and an office 
visit on January 20, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the discharge day management services described by code 
99239 billed for date of service June 24, 2023. 
 
You asked the Plan to pay for 99239. You say that 99239 should be paid as billed because it is supported in the 
documentation. The Plan denied your request. The Plan says 99239 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 99239 is hospital inpatient or observation discharge day 
management; more than 30 minutes on the date of the encounter. 
 
We find that CPT code 99239 is not supported in the medical record. Specifically, the code definition is time-
based, and the records submitted for review do not document the total time spent providing the services described by this code. Based on this information, we decided that Medicare rules for coverage of 99239 have 
not been met. Therefore, we decided that the Plan does not have to pay for the discharge day management 
services described by code 99239 billed for date of service June 24, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the EsoGuard test (0114U) provided July 24, 2023. 
 
You asked the Plan to pay for the EsoGuard test. You say that please review the attached documentation. The 
Plan denied your request. The Plan says this testing is considered non-covered after the MolDX program 
evaluation. 
 
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. Per the DEX Diagnostics Exchange Registry, this testing is 
considered non-covered after the MolDX program evaluation. Based on this information, we decided that 
Medicare rules for coverage of the EsoGuard test have not been met. Therefore, we decided that the Plan does 
not have to pay for the EsoGuard test (0114U) provided July 24, 2023.
Appeal type: Lab
Decision: Favorable

 
We decided that the Plan has to pay for PrismRA testing (81479) provided on April 17, 2023. 
 
You asked the Plan to pay for PrismRA testing. You say that this test was medically necessary and is supported 
in the records provided. The Plan denied your request. The Plan says that this test was considered non-covered 
at the time of service. 
 
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and 
diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or 
payment. 
 
The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their 
decision to deny your request. We find that the requested test is listed in the DEX database as covered. This 
determination was made and is specific to the test at issue. There is no evidence available to show that the test 
in question was not covered on the date of service. In addition, the LCD L38294 cited by the Plan does not 
apply to the state where this test was performed. The Plan has not substantiated their denial in this case. 
Therefore, we decided that the Plan has to pay for PrismRA testing (81479) provided on April 17, 2023.  
 
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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99100 billed for date of service July 3, 2023. 
 
You asked the Plan to pay for procedure code 99100. You say that the services were provided, and payment 
should be rendered. The Plan denied your request. The Plan says procedure code 99100 is considered bundled 
and 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 procedure code. 
 
We find that procedure code 99100 has a status indicator of B on the Physician Fee Schedule. This means that 
procedure code 99100 is not separately payable. Based on this information, we decided that Medicare rules for 
coverage of procedure code 99100 have not been met. Therefore, we decided that the Plan does not have to pay 
for procedure code 99100 billed for date of service July 3, 2023.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to waive the cost share for the comprehensive eye exam and the 
aflibercept injection provided on July 26, 2023. 
 
You asked the Plan to waive the cost share for the eye exam and injection. You say that you do not understand 
why these services were not paid in full. 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 20%  coinsurance for in-network Medicare Part B drugs. The Plan contract also says that the enrollee must pay a $20 
copayment for all other in-network Medicare-covered vision services. 
 
You have been asked to pay $700.54, which is 20% coinsurance of the allowed amount for the injection 
($3,502.68 allowed amount x 20% coinsurance = $700.54). This item/service falls within the Medicare Part B 
prescription drugs benefit category.  
 
You have also been asked to pay a $20 copayment for the eye exam. You have been asked to pay a total of 
$720.54 ($700.54 coinsurance + $20 copayment = $720.54). This service falls within the vision 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 cost share for the comprehensive eye exam and the aflibercept 
injection provided on July 26, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the pneumatic compression device (E0650) pneumatic 
appliances (E0673, E0666) and orthotics management and training (97760) provided on May 23, 2023, to June 
13, 2023, by an out-of-network (OON) provider.  
 
You asked the Plan to pay for the pneumatic compression device, appliances and training. You say that you are 
requesting reconsideration based on medical necessity for this enrollee and evidence based medical literature 
that substantiate the efficacy of the treatment rendered. The Plan denied your request. The Plan says enrollees 
must receive their medical services from an in-network provider with the exception being urgent or emergent services. Non-emergent services with non-contracted providers require prior authorization before services 
being rendered. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The requested provider in this case is not a network provider with the Plan. The Plan had network providers 
available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the 
item/service at issue. We found no exception that would require the Plan to pay for these items/services. 
Therefore, we decided that the Plan does not have to pay for the pneumatic compression device (E0650) 
pneumatic appliances (E0673, E0666) and orthotics management and training (97760) provided on May 23, 
2023, to June 13, 2023, by an out-of-network (OON) provider.