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

 
We decided that the Plan does not have to pay for surgical services (CPT 19361 and CPT 15002) provided to the enrollee 
on August 14, 2020. 
 
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 CPT codes 19361 and 15002 have an MUE value of 1 and MAI indicator is "2" but billed 2 units. 
 
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 the denied codes is: 
 
CPT 19361: 
 
Breast reconstruction with latissimus dorsi flap, without prosthetic implant 
 
CPT 15002: 
 
Surgical preparation or creation of recipient site by excision of open wounds, burn eschar, or scar (including 
subcutaneous tissues), or incisional release of scar contracture, trunk, arms, legs 
 
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 services. Our reviewer says that the services at issue in this case 
were not supported by the medical records. Our physician reviewer found both of the denied codes have a Medically 
Unlikely Edit of 1 unit per day. The services were not billed in accordance to the Medicare National Correct Coding 
Initiative Policy and, therefore it is not eligible for payment. 
 
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 services have not been met. Therefore, we decided that the Plan does not have to pay for surgical 
services (CPT 19361 and CPT 15002) provided to the enrollee on August 14, 2020.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pay for home infusion therapy services (HCPCS S9338) provided to 
the enrollee on August 12, 2020. 
 
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 this is an invalid procedure code for this service. 
 
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 HCPCS code S9338 is "Home infusion therapy, 
immunotherapy (e.g., intravenous immunoglobulin, interferon); administrative services, professional pharmacy 
services, care coordination, and all necessary supplies and equipment drugs and nursing visits coded 
separately), per diem." 
 
We find that HCPCS code S9338 is not supported in the medical record. Specifically, this code has a status 
indicator of I according to the Medicare Physician's Fee Schedule. This indicates that the code is not valid for 
Medicare purposes. 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 home infusion therapy services 
(HCPCS S9338) provided to the enrollee on August 12, 2020.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve lumbar surgery (22558).
You asked the Plan to pre-approve lumbar surgery. You say that the services are necessary. The Plan denied your request. The Plan says medical necessity has not been established. Therefore, coverage criteria has not been met.
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 lumbar surgery. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found criteria for lumbar fusion surgery is not met. There is no documentation of segmental spinal instability. Fusion surgery is not needed. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of lumbar surgery have not been met. Therefore, we decided that the Plan does not have to pre-approve lumbar surgery (22558).
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the self-administered drugs provided from July 15, 2020 to 
July 17, 2020. 
 
You asked the Plan to pay for the self-administered drugs. You say that you would like the Plan to reconsider 
their denial of payment. The Plan denied your request. The Plan says the self-administered drugs provided to 
you are not covered under your Medicare Part B benefit. 
 
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-
administered drugs. The self-administered drugs requested here are not among the types which are covered by 
Medicare Part B. Therefore, we decided that the Plan does not have to pay for the self-administered drugs 
provided from July 15, 2020 to July 17, 2020.  
 
Benefits for the self-administered drugs may be available under Medicare Part D. Contact the Plan that 
administers Part D benefits for further information concerning any benefits and appeal rights.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the BLS non-emergency ambulance (A0428) and ground 
mileage (A0425) provided on February 13, 2020 by an out of network (OON) provider. 
 
You asked the Plan to pay for the ambulance service. You say that the attached documents detail the medical 
necessity and warrants the need for an ambulance transport on the date of service. The Plan denied your 
request. The Plan says non-emergency ambulance transportation requires prior authorization prior to 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. 
 
Medicare pays for ambulance services only when they are medically reasonable and necessary.  Page 61 of the 
plan contract says that prior authorization is required for non-emergency ambulance transportation. 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 BLS non-emergency 
ambulance (A0428) and ground mileage (A0425) provided on February 13, 2020 by an out of network (OON) 
provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay an additional amount for eyeglasses provided on July 13, 2020. 
 
You asked the Plan to pay an additional amount for the eyeglasses. The Plan denied your request. The Plan 
says the vision services have been paid correctly with a $200 allowance. 
 
Medicare generally does not cover routine eyewear services. However, the Plan offers a routine eyewear 
benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case.  
 
We looked at the file and the Plan's rules. The file shows the Plan eyewear benefit allowance of $200 has been 
paid. Therefore, we decided that the Plan does not have to pay an additional amount for eyeglasses provided on 
July 13, 2020.
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pay for acupuncture services (97813, 97810, 97811, 97814) provided from 
June 25, 2020, to July 29, 2020. 
 
You asked the Plan to pay for acupuncture services. You say that this is a Medicare-covered service. The Plan 
denied your request. The Plan says that this is not covered by the Plan. 
 
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 rules also say that plans must pay for a medical service or item if regular Medicare would pay for 
it in this case, and that for services performed on or after January 21, 2020, Medicare will now provide limited 
coverage of acupuncture for patients with chronic low back pain (CLBP). 
 
The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their 
decision to deny your request. Specifically, the submitted documentation does not address whether the 
Medicare criteria for coverage have been met and does not included medical records or other information 
necessary for this determination. Therefore, we decided that the Plan has to pay for acupuncture services 
(97813, 97810, 97811, 97814) provided from June 25, 2020, to July 29, 2020.  
 
 
 
 
 
 
 
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 waive the coinsurance for brachytherapy provided on March 19, 
2020. 
 
You asked the Plan to waive the coinsurance for brachytherapy. You say that you think there was a 
misinterpretation of your operations and radiation treatments. The Plan denied your request. The Plan says you 
were charged the coinsurance 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 outpatient hospital services.  
 
You have been asked to pay 20% coinsurance for brachytherapy. Brachytherapy falls within the outpatient 
hospital 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 coinsurance for brachytherapy 
provided on March 19, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the cost share for the inpatient mental health care provided 
from August 28, 2020 to September 15, 2020. 
 
You asked the Plan to waive the cost share for the inpatient mental health care. You say that you feel you 
should not be responsible for this cost share amount and you would like the Plan to reconsider your request. 
The Plan denied your request. The Plan says you received inpatient mental health care on the dates of service at 
issue in this appeal. The Plan says that the correct cost share has applied per your contract with the Plan. 
 
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 $320 
copayment per day for days 1-5 for Inpatient mental health care. There is a $1600 out-of-pocket limit per stay. 
 
We looked at the file, the Plan's contract and Medicare rules. The file shows that you received inpatient mental 
health care from August 28, 2020 to September 15, 2020. You have been asked to pay a $320 copayment per 
day for days 1-5 for the inpatient mental health care, totaling $1600. The inpatient mental health care falls 
within the Inpatient mental health 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 
inpatient mental health care provided from August 28, 2020 to September 15, 2020.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pay for the home infusion therapy services with CPT codes 99601, S9363 and S9810 provided on June 25, 2020.
You asked the Plan to pay for CPT codes 99601, S9363 and S9810. You say that you would like the Plan to reconsider their denial of payment. The Plan denied your request. The Plan says the services are not covered.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. We looked at the file and Medicare rules. In this case, CPT codes 99601, S9363 and S9810 have a status code of "I" under the Medicare Physicians Fee Schedule Database (MPFSDB) and are not valid for Medicare purposes. Medicare uses other codes for reporting of, and payment for, these services. Therefore, we decided that the Plan does not have to pay for the home infusion therapy services with CPT codes 99601, S9363 and S9810 provided on June 25, 2020.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approvea referral to an out-of-network provider.You asked the Plan to pre-approvethese services. You say that you disagree with the denial.The Plan denied your request. The Plan says the services are available from network providers.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-approvea referral to an out-of-network provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve compression stockings identified with code A6530. 
 
You asked the Plan to pre-approve the compression stockings. You say that this should be paid for. The Plan 
denied your request. The Plan says this is not covered under any normal circumstances. 
 
The Plan must follow Medicare rules. The rules say that compression stockings described by code A6530 are 
noncovered because they do not meet the statutory definition of a surgical dressing.  
 
Although this item may be appropriate, it does not fall into a covered benefit category and cannot be paid for 
by Medicare or the Plan. Therefore, we decided that the Plan does not have to pre-approve compression 
stockings identified with code A6530.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for DecisionDx-Melanoma testing (81599) provided on April 
24, 2020. 
 
You asked the Plan to pay for DecisionDx-Melanoma testing. You say that this is a covered service. The Plan 
denied your request. The Plan says the criteria for coverage have not been met. 
 
The Plan must follow Medicare rules. Medicare rules say that the DecisionDx-Melanoma test is covered only 
when the patient has been diagnosed with clinical stage sentinel lymph node biopsy (SLNB) eligible T1b and 
T2 cutaneous melanoma tumors. 
 
We looked at the file and Medicare rules. The submitted medical records do not show that the enrollee has been 
diagnosed with clinical stage sentinel lymph node biopsy (SLNB) eligible T1b and T2 cutaneous melanoma 
tumors. Based on this information, we decided that Medicare rules for coverage of DecisionDx-Melanoma 
testing have not been met. Therefore, we decided that the Plan does not have to pay for DecisionDx-Melanoma 
testing (81599) provided on April 24, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approvea second opinion office visit (99202) to be provided by an out of network (OON) provider.You asked the Plan to pre-approvea second opinion office visit to be provided by an OON provider. You say that the services are necessary.The Plan denied your request. The Plan says there are in-network providers that are able to provide these services. Therefore, coverage criteria has not been met.Medicare rules say that plans can require enrolleesto 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-approvea second opinion office visit (99202) to be provided by an out of network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a stair glide. 
 
You asked the Plan to pre-approve a stair glide. You say that you require the stair lift for your second floor 
apartment. The Plan denied your request. The Plan says this item is not a covered benefit. 
 
The Plan covers all items that Medicare covers. Medicare rules state that stair lifts are not covered because they 
are not primarily medical in nature.  
 
While a stair lift may be appropriate in this case, neither the Plan nor Medicare offers coverage of this item. 
Therefore, we decided that the Plan does not have to pre-approve a stair glide.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the medical services provided on May 10, 2020, by an OON 
provider. 
 
You asked the Plan to pay for home health services. You say that these services were necessary. The Plan 
denied your request. The Plan says these services were rendered with no 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 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 May 10, 2020, 
by an OON provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the comprehensive oral exam (D0150), prophylaxis (D1110), 
and the complete series of x-rays (D0210) provided on July 14, 2020. 
 
You asked the Plan to pay for the dental services. You say that you were given 3 in network dentists in your 
area. You say that they are all over 40 miles away from your home, 1 way. You say that you cannot sit in the 
car that long. You also say that you are on a limited income and would appreciate reconsideration. The Plan 
denied your request. The Plan says the provider in this case is out of network. The Plan says that dental 
services that you receive out of network are not covered. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plan?s coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, care rendered by a provider that is not 
part of the supplemental dental network is not covered. Therefore, we decided that the Plan does not have to 
pay for the comprehensive oral exam (D0150), prophylaxis (D1110), and the complete series of x-rays (D0210) 
provided on July 14, 2020.
Appeal type: Hospice
Decision: Unfavorable

 
We decided that the Plan does not have to pay for ambulance services provided on July 11, 2020. 
 
You asked the Plan to pay for the ambulance services. The Plan denied your request. The Plan says Original 
Medicare would be responsible for payment of all Medicare covered services related or unrelated to the 
member?s terminal condition. The Medicare hospice benefit, through fee-for-service Medicare, covers all 
hospice care from the effective date of election to the date of discharge or revocation. During the election, fee-
for-service Medicare also covers attending physician services and all care unrelated to the terminal illness until 
the first day of the month following the month in which hospice was revoked or discharged 
 
Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice 
services. Medicare hospice pays for claims related to the terminal illness. The rules say that the Plan may direct 
the provider to bill Medicare directly for these services.  
 
The enrollee was under the Medicare hospice benefit for the date of service at issue in this appeal. Therefore, 
we decided that the Plan does not have to pay for ambulance services provided on July 11, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to waive the cost share amount for the partial upper denture (D5213) 
provided on June 22, 2020. 
 
You asked the Plan to waive the cost share amount for the dental item. You say that due to the pandemic, you 
are having hardships paying your bills. The Plan denied your request. The Plan says the partial denture is 
payable at a 30% coinsurance. The Plan says that you are responsible for the remaining 70% coinsurance. The 
Plan also says that no additional payment will be made for the partial denture. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plan?s coverage rules apply in this case.  
 
Though the Plan offers a dental benefit in excess of Medicare coverage, there is a 70% coinsurance for partial 
dentures. Coinsurance is a contractual obligation you agreed to when you enrolled in the Plan?s dental 
coverage. Therefore, we decided that the Plan does not have to waive the cost share amount for the partial 
upper denture (D5213) provided on June 22, 2020.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pay for the home health services provided to the enrollee from 
September 17, 2019. 
 
You asked the Plan to pay for home health services. You say that you would like the Plan to reconsider their 
denial of payment. The Plan denied your request. The Plan says the claim was not submitted correctly per 
Medicare guidelines. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
 
We looked at the file and Medicare rules. Home health care services must be billed on a UB-04 form per 
Medicare guidelines. Based on this information, we decided that Medicare rules for completing the claim for 
home health services have not been met. Therefore, we decided that the Plan does not have to pay for the home 
health services provided to the enrollee from September 17, 2019.