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

 
We decided that the Plan does not have to pay for the surgical services rendered on March 10, 2020. 
 
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 procedure codes 20702 and 20700 are 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 20702 is manual preparation and insertion of drug-
delivery device(s), intramedullary (List separately in addition to code for primary procedure). The definition of 
code 20700 is manual preparation and insertion of drug-delivery device(s), deep (e.g., subfascial) (List 
separately in addition to code for primary procedure). 
 
We find that CPT codes 20702 and 20700 are not supported in the medical record. Specifically, these are add-
on codes that were not billed with a required primary procedure 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 the surgical services rendered on March 10, 2020.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the medical services provided on August 18, 2020 by an out 
of network provider. 
 
You asked the Plan to pay for the incision procedure. You say that the Plan should pay this claim. The Plan 
denied your request. The Plan says you did not request prior authorization. 
 
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 has network providers 
available who can provide the services at issue in this appeal. The Plan did not pre-approve the service at issue. 
We found no exception that would require the Plan to pay for these services. Therefore, we decided that the 
Plan does not have to pay for the medical services provided on August 18, 2020 by an out of network provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the services provided on June 5, 2019. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the claim was 
submitted after the timely filing limit. 
 
The Plan follows Medicare rules. The rules say that claims for services furnished on or after January 1, 2010, 
must be filed no later than one calendar year after the date of service. 
 
The record shows that a claim for the services was not filed until July 23, 2020. This means that more than one 
calendar year from the date of service had passed before a claim was filed. Therefore, we decided that the Plan 
does not have to pay for the services provided on June 5, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the knee orthosis and suspension sleeve provided on July 9, 
2020. 
 
You asked the Plan to pay for the knee orthosis (L1833) and suspension sleeve (L2397). You say that the Plan 
should pay this claim. The Plan denied your request. The Plan says there were no claims from the ordering 
physician within the last 6 months prior to the date of service. 
 
The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when there are both a 
physician order and proof of delivery.  
 
The record does not contain a valid proof of delivery for the supplies provided in this case. The Delivery Ticket 
does not have the tracking number on it and the Proof of Delivery does not have a description of the items 
delivered. Therefore, we decided that the Plan does not have to pay for the knee orthosis and suspension sleeve 
provided on July 9, 2020.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ambulance services provided. 
 
You asked the Plan to pay for the ambulance services. You say that this service is medically necessary. The 
Plan denied your request. The Plan says these services are not a covered benefit. 
 
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. 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 services 
provided.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the intermittent limb compression device provided on August 
5, 2020. 
 
You asked the Plan to pay for the intermittent limb compression device (E0651, E0667). You say that the 
device was medically necessary. The Plan denied your request. The Plan says pneumatic compression devices 
are not covered by Medicare if the enrollee has not had a trial of conservative therapy. 
 
The Plan follows Medicare rules. The rules state that Medicare covers pneumatic devices when medically 
necessary for the treatment of lymphedema and/ or for the treatment of chronic venous insufficiency with 
venous stasis ulcers. 
 
The file does not show that the enrollee has had clinical treatment over the course of a 4 week period. 
Therefore, we decided that the Plan does not have to pay for the intermittent limb compression device provided 
on August 5, 2020.
Appeal type: Practitioner Services
Decision: Favorable

We decided that the Plan has to pay for the urgent care visit provided on June 22, 2020. 
You asked the Plan to pay for the urgent care visit. You say that the visit was for a COVID test which is fully 
covered. The Plan denied your request. The Plan says that the copayment applied correctly. 
 
The Plan must follow Medicare rules. Medicare rules say that Plans must cover at no cost sharing, any visit 
which results in an order for a COVID test when that visit was provided as an evaluation for purposes of 
determining the need for such test. 
 
We looked at the file and Medicare rules. The file indicates that a specimen was taken and transported to a lab. 
This supports that this visit resulted in an order for a COVID test. The documentation also supports that this 
visit was for the purposes of determining the need for a COVID test. We found no language in the rules which 
allows cost sharing to be applied for any reason, including the Plan's rationale that this test was elective, due to 
a lack of symptoms or exposure to a known positive case. We find that, based on the available information, 
waiver of cost sharing for this urgent care visit is required by Medicare regulations. Therefore, we decided that 
the Plan has to pay for the urgent care visit provided on June 22, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an expandable control system for the power wheelchair. 
 
You asked the Plan to pre-approve an expandable control system. The Plan denied your request. The Plan says 
the enrollee's upper limb strength and function are adequate to control the power options using their own 
switches. 
 
The Plan follows Medicare rules. Medicare rules say that wheelchair options and accessories are only covered 
under certain medical indications.  
 
 
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 an expandable control system. Our 
physician reviewer found that the documentation does not reveal that the enrollee needs an expandable 
controller to operate proportional input devices, non-proportional input devices, or 3 or more powered seating 
actuators through the drive control. The enrollee has sufficient strength in the upper extremities and functional 
ability to operate any power options through their own individual switches. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of an expandable control system have not been met. Therefore, we decided that the 
Plan does not have to pre-approve an expandable control system for the power wheelchair.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the arterial studies (93886, 93880) provided on August 19, 
2020, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for OON arterial studies. You say that these services were requested by the 
physician. The Plan denied your request. The Plan says these services were not authorized. 
 
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 has network providers 
available who can provide 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 arterial studies (93886, 93880) provided on 
August 19, 2020, by an out-of-network (OON) provider.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the YAG laser capsulotomy (66821) 
provided June 15, 2020. 
 
You asked the Plan to waive the copayment for the YAG laser capsulotomy. You say that you have seen this 
doctor for several years and have never had so much trouble with the claims department. The Plan denied your 
request. The Plan says the claim processed and the correct copayment applied per the plan benefits 
 
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 $50 
copayment for physician specialists services (including surgery second opinion, Medicare-covered telehealth or 
urgently needed services).  
 
You have been asked to pay $50 copayment for the YAG laser capsulotomy. The YAG laser capsulotomy falls 
within the Physician/practitioner services, including doctor's 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 copayment for the YAG laser capsulotomy (66821) provided June 15, 2020.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ambulance services provided
on July 4, 2020. 
 
You asked the Plan to pay for the ambulance services. You say that you were following the COVID executive 
order for treatment in place. The Plan denied your request. The Plan says these services are not a covered 
benefit. 
 
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 4, 2020. 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 services provided  on July 4, 2020.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the treatment of a hip dislocation (27265) provided on 
February 22, 2020. 
 
You asked the Plan to pay for the treatment of a hip dislocation. You say that this is supported in the records. 
The Plan denied your request. The Plan says this exceeds the MUE for this code. 
 
The Plan must follow Medicare rules. Medicare rules say that claims submitted where the unit of service 
exceeds the MUE value for the HCPCS/CPT code will be denied. 
 
In this case, the MUE for CPT code 27265 is 1. You billed 2 units of this code, exceeding the MUE. Based on 
this information, we decided that Medicare rules for coverage of the treatment of a hip dislocation have not 
been met. Therefore, we decided that the Plan does not have to pay for the treatment of a hip dislocation 
(27265) provided on February 22, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the physical therapy services provided on August 3, 2020, by 
an out-of-network provider. 
 
You asked the Plan to pay for the physical therapy services. You say that the Plan should pay this claim. The 
Plan denied your request. The Plan says you did not request prior authorization. 
 
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 has network providers 
available who can provide the services at issue in this appeal. The Plan did not pre-approve the service at issue. 
We found no exception that would require the Plan to pay for these services. Therefore, we decided that the 
Plan does not have to pay for the physical therapy services provided on August 3, 2020, by an out-of-network 
provider.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pay for the psychiatric evaluation provided on August 1, 2020 by an 
out of network provider. 
 
You asked the Plan to pay for the psychiatric evaluation. You say that your doctor treated the enrollee in good 
faith. The Plan denied your request. The Plan says you did not request prior authorization. 
 
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 has network providers 
available who can provide the services at issue in this appeal. The Plan did not pre-approve the service at issue. 
We found no exception that would require the Plan to pay for these services. Therefore, we decided that the 
Plan does not have to pay for the psychiatric evaluation provided on August 1, 2020 by an out of network provider.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve personal care assistance (PCA) services. 
 
You asked the Plan to pre-approve the requested PCA services. You say that you feel that due to the enrollee's 
condition, she would benefit from assistance in the home at least three days a week. The enrollee is already 
receiving home health therapy but the agency that provides the therapy does not also provide PCA services. 
The Plan denied your request. The Plan says home health services have been approved. However, the type of 
unskilled home health care you are requesting is not covered by Medicare. 
 
The Plan must follow Medicare rules. Medicare rules say that custodial care is personal for a person who does 
not need ongoing care from trained medical or paramedical staff. Custodial care is excluded from Medicare 
coverage. 
 
In this case, review of the facts shows that the services being requested are not skilled paramedical services to 
be provided by a certified home health aide, but rather, general PCA services to assist with activities of daily 
living. This is considered custodial in nature and cannot be covered by Medicare or the Plan. Therefore, we 
decided that the Plan does not have to pre-approve personal care assistance (PCA) services.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the esophagus biopsy provided on July 20, 
2020. 
 
You asked the Plan to waive the copayment for the esophagus biopsy. You say that you thought insurance 
would cover the entire bill. You say that you cannot afford this. The Plan denied your request. The Plan says 
the copayment applied 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 $375 
copayment for Medicare-covered surgery or other services provided to you at an in-network outpatient hospital, 
including but not limited to hospital or other facility charges and physician or surgical charges. 
 
You have been asked to pay a $375 copayment for the esophagus biopsy. The esophagus biopsy falls within the 
"Outpatient Surgery and Other Medical Services Provided at Hospital Outpatient Facilities and Ambulatory 
Surgical Centers" 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 esophagus biopsy 
provided on July 20, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the eye refraction provided on July 31, 2020. 
 
You asked the Plan to pay for the eye refraction. You say that you are requesting the refraction be covered by 
the Plan. The Plan denied your request. The Plan says you exhausted your benefit. The Plan must follow 
Medicare rules. The rules say that Medicare does not cover routine vision services and eyewear. The Plan only 
covers the refraction once per calendar year with a routine vision visit and you previously utilized the refraction 
benefit on June 22, 2020. Therefore, we decided that the Plan does not have to pay for the eye refraction 
provided on July 31, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the medical services provided on July 3, 2020, by an OON 
provider. 
 
You asked the Plan to pay for a domiciliary or rest home visit. You say that these medically necessary services 
were provided to the enrollee in good faith. The Plan denied your request. The Plan says rules for payment 
have not been met. 
 
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 has network providers 
available who can provide 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 medical services provided on July 3, 2020, by 
an OON provider.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Superion interspinous spacer for the enrollee. 
 
You asked the Plan to pre-approve these services. You say that these services are medically necessary. The 
Plan denied your request. The Plan says that a review of the current medical literature indicates that this service 
is considered experimental and investigational. 
 
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 these services. Our reviewer says that 
the requested services are not considered medically reasonable and necessary in this case. The spacer remains 
experimental. More research is needed to show safety and efficacy. Our physician reviewer found that the 
enrollee's condition does not meet Medicare criteria for these services. 
 
We looked at this physician's review, the file, and Medicare rules. 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 pre-approve a Superion interspinous spacer for the enrollee.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a power scooter. 
 
You asked the Plan to pre-approve these services. You say that the scooter will assist your mobility. The Plan 
denied your request. The Plan says the services are not medically necessary. 
 
The Plan follows Medicare rules. Medicare rules say that a PMD will not be covered if the patient does not 
have mobility deficit that impairs their participation in MRADLs, the patient?s condition can be ameliorated by 
a walker, cane or manual wheelchair, or the patient is not capable of safely operating the requested PMD.  
 
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 these services. Our reviewer says that 
the services are not medically necessary. Our physician reviewer found the records show that you have a 
personal mobility limitation, but it does not impair your ability to participate in mobility-related activities of 
daily living (MRADLs) in the home. Your mobility deficit is currently helped by a walker. The power scooter 
is therefore not reasonable or 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 these services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a power scooter.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve 2-3 hours companionship with cooking and cleaning. 
 
You asked the Plan to pre-approve the services. You say that the member lives alone with a broken arm and 
cannot cook. The Plan denied your request. The Plan says Medicare states these services are not covered. 
 
The Plan must follow Medicare rules. The rules say that HHA services may be covered if it is medically 
necessary for the enrollee to receive skilled nursing or therapy. We looked at the file, and Medicare rules. 
Based on this information, we decided that Medicare rules for coverage of the services have not been met. 
According to Medicare, companionship with cooking and cleaning services is not one of the services covered 
because it is considered personal care that does not require skilled nursing or medical services. Therefore, we 
decided that the Plan does not have to pre-approve 2-3 hours companionship with cooking and cleaning.