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

 
We decided that the Plan does not have to pay for anesthesia services (CPT 01402) provided to the enrollee on 
June 8, 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 the billed code cannot be verified. 
 
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 01402 is "anesthesia for open or surgical arthroscopic 
procedure on knee join; total knee arthroplasty." 
 
We asked our coding 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 coding reviewer found the medical 
records do indicate that 1 hour and 42 minutes of anesthesia services were delivered to the enrollee on June 8, 
2020. However, 102 unit of this service was billed. 1 hour and 42 minutes does not equate to 102 units of 
service, therefore the units cannot be verified. 
 
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 anesthesia services (CPT 01402) provided to the enrollee on June 8, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have pay for intermittent limb compression device. 
 
You asked the Plan pay for intermittent limb compression device. You say that the enrollee requires the device. 
The Plan denied your request. The Plan says the documentation failed to prove that sufficient evidence of four-
week trial of conservative therapy. 
 
The Plan follows Medicare rules. The rules state that a PCD coded as E0651 is covered for the treatment of 
lymphedema and/ or for the treatment of chronic venous insufficiency with venous stasis ulcers. A four-week 
trial of conservative therapy demonstrating failed response to treatment 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 home usage of conservative therapy including compression garments, exercise and 
elevation.  Therefore, we decided that the Plan does not have pay for intermittent limb compression device.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve SNF care provided to from November 30, 2020, 
forward. 
 
You asked the Plan to pre-approve SNF care. You say that the stay is medically necessary. The Plan denied 
your request. The Plan says the stay is not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors 
listed above are met. Custodial care is 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 SNF care. Our reviewer says that daily 
skilled services are not necessary. Our physician reviewer found there are no identifiable skilled nursing 
service needs. There are identifiable skilled therapy service needs. The beneficiary does not require skilled 
nursing or therapy services on a daily basis. This beneficiary does not meet severity of illness or intensity of 
service criteria for an inpatient basis in a SNF setting. 
 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of SNF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve SNF care provided to from November 30, 2020, forward.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services rendered on July 29, 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 screening tests are not covered. 
 
The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few 
tests listed above, are not covered. 
 
The test at issue in this appeal, molecular genetic screening, was requested solely for screening purposes. 
Medicare does not cover this test solely for screening purposes. Therefore, we decided that the Plan does not 
have to pay for the laboratory services rendered on July 29, 2020.
Appeal type: DME/ Orthotics
Decision: Favorable

 
We decided that the Plan has to pre-approve CPT Code A5512 and A5500. 
 
You asked the Plan to pre-approve the supplies. You say that the diabetic shoe and inserts are medically 
necessary. The Plan denied your request. The Plan says that this item may be covered for people with diabetes. 
The Plan states there must be documentation showing the member has a foot condition and needs diabetics 
hoes. The Plan states the member must be under the care of a certifying physician for their diabetes. The Plan 
 
 
states the Medicare rule says a certifying physician may be a doctor of medicine or a doctor of osteopathy. The 
Plan states six months prior to receiving diabetic shoes, the member must have had an in-person visit with their 
certifying physician. The Plan states the member must also meet with a supplier for an in-person evaluation 
prior to receiving diabetic shoes and the records sent in by the doctor do not show the Plan this. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the supplies. Our physician reviewer 
found the patient does indeed have foot deformity including hammertoe and hallux valgus; the patient also has 
two (2) foot ulcers they have diabetes mellitus DM. Therefore, the patient is a candidate for custom footwear to 
minimize future foot ulcers and infections. 
 
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 supplies have been met. Therefore, we decided that the Plan has to pre-
approve CPT Code A5512 and A5500.  
 
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 the pneumatic compression device (E0651) and sleeves 
(E0667) provided to the enrollee on July 22, 2020. 
 
You asked the Plan to pay for these services. You say that these services were medically necessary. The Plan 
denied your request. The Plan says that the only time that a segmented, calibrated gradient pneumatic 
compression device would be covered is when the individual has unique characteristics that prevent them from 
receiving satisfactory pneumatic compression treatment using a non-segmented device. 
 
The Plan follows Medicare rules. The rules state that Medicare covers pneumatic devices when the above 
criteria have been met. 
 
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 these services. Our reviewer says that these 
services were not medically reasonable and necessary for the enrollee in this case. The enrollee does have 
edema in the affected lower extremity. There is no specific documentation demonstrating evidence of one or 
more venous stasis ulcer(s). There is no specific documentation indicating that the ulcer(s) failed to heal after a 
six-month trial of conservative therapy directed by the treating practitioner. Our physician reviewer found that 
the enrollee's condition did 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 pay for the pneumatic compression device (E0651) and sleeves (E0667) provided to the enrollee on 
July 22, 2020.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services provided to the enrollee on May 26, 2020. 
 
You asked the Plan to pay for this service. You say that this claim should be paid. The Plan denied your 
request. The Plan says Provider is appealing the denied unlisted CPT code 81519. Medicare requires a narrative 
explanation of unlisted CPT codes on the claim or attached to the claim. This information was not submitted.  
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate codes. In this case, insufficient medical records and claim 
narrative have been submitted to support payment.  Based on this information, we decided that Medicare rules 
for coverage of this service have not been met. Therefore, we decided that the Plan does not have to pay for lab 
services provided to the enrollee on May 26, 2020.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the breast ultrasound you had on July 17, 
2020. 
 
You asked the Plan to waive the copayment for the breast ultrasound. You say that you thought you just had a 
normal screening mammogram, not an ultrasound. The Plan denied your request. The Plan says you were 
charged this copayment correctly because you actually had an ultrasound, not a screening mammogram. 
 
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 $60 
copayment for ultrasounds.  
 
You have been asked to pay a $60 copayment for the breast ultrasound. This copayment applies regardless of 
the reason for this test. 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 breast ultrasound you had on 
July 17, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the services provided on June 23, 2020. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says this provider is not 
eligible for payment. 
 
The Plan must follow Medicare rules. Medicare rules say that no provider or supplier shall receive payment for 
services furnished to a Medicare beneficiary unless the provider or supplier is enrolled in the Medicare 
program. 
 
We looked at the file and Medicare rules. The provider in question is on the Medicare preclusion list. This 
means that the provider is not eligible to participate in the Medicare program, and cannot be paid for Medicare 
Advantage items or services. 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 the services provided 
on June 23, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a spinal cord stimulator. 
 
You asked the Plan to pre-approve the requested services. The Plan denied your request. The Plan says the 
enrollee has not had a complete exam by an independent team of different types of experts. 
 
The Plan follows Medicare rules. Medicare rules say that spinal cord stimulators 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 the requested services. Our physician 
reviewer found that the enrollee has chronic knee pain and has undergone arthroscopy. She has seen a 
psychologist for clearance for an SCS trial. She was also evaluated by an Orthopedic Surgeon and a Pain 
Management Physician's Assistant. The physical exam does not demonstrate Allodynia or Hyperalgesia, 
differences in skin temperature, edema, or sweating. She does have decreased range of motion, but there is no 
documentation of changes in skin, hair or nails or motor symptoms. The enrollee does not meet the criteria for 
causalgia. This procedure is not indicated. Therefore, the request is not medically reasonable or 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 the requested services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a spinal cord stimulator.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an ECG provided on May 11, 2020. 
 
You asked the Plan to waive the copayment for an ECG. You say that the test was part of a routine physical 
and you disagree with the charges. The Plan denied your request. The Plan says the claims were processed 
correctly and you are being charged the correct amount. 
 
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 non-radiological diagnostic services. 
 
You received an ECG on May 11, 2020. ECG?s are not considered as a preventative service and are subject to 
cost-sharing charges. Therefore, you are responsible to pay the allowed amount of $16.88, which is less than 
the $30 copayment.   
 
You have been asked to pay $16.88 for an ECG. An ECG falls within the outpatient diagnostic tests and 
therapeutic services and supplies 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 ECG provided on May 11, 2020.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the genetic testing services provided on June 3, 2020. 
 
You asked the Plan to pay for the genetic testing services. You say that you would like the plan to reconsider 
their denial. The Plan denied your request. The Plan says the services billed are not payable. 
 
The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few 
tests listed above, are not covered. 
 
The genetic testing at issue in this appeal were requested solely for screening purposes. Medicare does not 
cover this test solely for screening purposes. Therefore, we decided that the Plan does not have to pay for the 
genetic testing services provided on June 3, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for a radiographic survey of the whole mouth, usually consisting 
of 14-22 periapical and posterior bitewing images intended to display the crowns and roots of all teeth, 
periapical areas and alveolar bone (D0210) provided on August 4, 2020. 
 
You asked the Plan to pay for a radiographic survey of the whole mouth, usually consisting of 14-22 periapical 
and posterior bitewing images intended to display the crowns and roots of all teeth, periapical areas and 
alveolar bone. You say that the service was medically necessary. The Plan denied your request. The Plan says 
you have exhausted your maximum allowed for this benefit. 
 
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. This benefit includes one 
panoramic X-Ray of complete series once every three years. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
among those covered under this benefit. Records show you received a complete series (D0210) on September 
25, 2017. This means your August 4, 2020, service was within the 3 year period. Therefore, we decided that the 
Plan does not have to pay for a radiographic survey of the whole mouth, usually consisting of 14-22 periapical 
and posterior bitewing images intended to display the crowns and roots of all teeth, periapical areas and 
alveolar bone (D0210) provided on August 4, 2020.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Pembrolizumab. 
 
You asked the Plan to pre-approve Pembrolizumab. You say that you recommend the addition of 
Pembrolizumab to chemotherapy for the enrollee. The Plan denied your request. The Plan says the coverage 
criteria has not been met. 
 
The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for anti-cancer 
drugs if they are medically accepted as safe and effective or appropriate for the particular use.  
 
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 Pembrolizumab. Our reviewer says that 
Pembrolizumab is not medically reasonable and necessary for the enrollee. Our physician reviewer found 
Pembrolizumab is not FDA approved for the requested use. Our reviewer found that the drug is not supported 
for the requested use in any of the CMS approved compendia. This reviewer did not find any supportive 
citations in a PubMed search. The citations listed and the one submitted by the prescriber do not reflect the 
enrollee's clinical situation. Our physician reviewer also found that the use is not listed as not indicated, not 
supported or not recommended in any of the compendia. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Pembrolizumab have not been met. Therefore, we decided that the Plan does 
not have to pre-approve Pembrolizumab.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the warranty provided on February 7, 2020. 
 
You asked the Plan to pay for the warranty. The Plan denied your request. The Plan says that this services is 
not covered. 
 
Medicare does not pay for hearing aids or related services. However, the Plan offers a hearing aid benefit that 
exceeds Medicare coverage. For that reason, the plan's coverage rules apply in this case.  
 
Though the Plan offers a hearing benefit in excess of Medicare coverage, the requested items or services are 
not among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the 
warranty provided on February 7, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the eyeglass services to be provided by an out of 
network (OON) provider. 
 
You asked the Plan to pre-approve the eyeglass services. You say that you would like the Plan to reconsider 
their denial. The Plan denied your request. The Plan says the requested services are neither emergent nor urgent 
to seek out-of-network care. The Plan says that there are in-network providers available to you that can provide 
the services you are requesting. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pre-approve care from out-of-network providers only in cases involving 
emergencies, out of area urgent care and care that cannot be provided by network providers. 
 
The requested provider in this case is not a network provider with the Plan. The Plan has network providers 
available who can provide the items/services at issue in this appeal. We found no exception that would require 
the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve 
the eyeglass services to be provided by an out of network (OON) provider.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the ambulance transport provided on June 
5, 2020. 
 
You asked the Plan to waive the copayment for the ambulance transport. You say that you should not have to 
pay for the second ambulance transfer. The Plan denied your request. The Plan says that you were 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 $200 
copayment for per ambulance trip.  
 
You have been asked to pay a $200 copayment for the ambulance transport. The ambulance transport falls 
within the ambulance trip benefit category. This means that you have been asked to pay the correct amount 
based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you 
enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for the 
ambulance transport provided on June 5, 2020.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for portable x-ray diagnostic services provided on January 13, 
2020. 
 
You asked the Plan to pay for the portable x-ray diagnostic services. The Plan denied your request. The Plan 
says he Plan requires utilization of network providers when possible and available, and requires authorization 
for certain services. No medical necessity for an out-of-network provider, such as an urgent or emergency 
situation, has been documented. 
 
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 did not pre-approve the 
services 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 portable x-ray diagnostic services provided on January 13, 2020.