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

We decided that the Plan does not have to pre-approve the Zoster (shingles) vaccine you received on August
15, 2019.
You asked the Plan to pre-approve the vaccine. You say that you were assured the service would be covered.
The Plan denied your request. The Plan says the services are not covered under your Part B plan.
In the absence of injury or direct exposure to illness, Medicare does not pay for or provide the vaccine. The
Plan follows the same rules.
Records do not show that you have been injured or directly exposed to any illness related to the vaccine.
Therefore, we decided that the Plan does not have to pre-approve the Zoster (shingles) vaccine you received on
August 15, 2019.
Benefits for the vaccine 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: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services.
You asked the Plan to pre-approve the LTACH services. You say that the services are necessary. The Plan denied your request. The Plan says the care required can be provided in the current inpatient hospital setting.
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 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 LTACH services. Our reviewer says that the requested LTACH care is not considered medically reasonable and necessary in this case. Our physician reviewer found the enrollee is currently undergoing treatment at an acute care hospital (ACH), having been admitted with altered mental status and bradycardia. The enrollee required intubation/ventilation and soon thereafter received a tracheotomy. The enrollee has been tolerating pressure support trials. It has not yet been established that the enrollee has failed weaning. There is no evidence that the enrollee requires services that are not currently available. As LTACHs and ACHs are licensed to provide the same level of care, there is no advantage in transferring the enrollee to the LTACH. The enrollee can remain at the current ACH until such time no acute services are required. The enrollee can then be transferred/discharged to a lower level of care for any ongoing long term care (LTC) needs. 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 LTACH services have not been met. Therefore, we decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services.
Appeal type: Hospice
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services, chest x-ray, routine ECG, and ED visit provided on January 2, 2020.
You asked the Plan to pay for the laboratory services, chest x-ray, routine ECG, and ED visit. You say that the claim has not been paid in full or under the terms of the contract for the services provided to this enrollee. 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 enrollee's terminal condition.
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 dates of service at issue in this appeal. Therefore, we decided that the Plan does not have to pay for the laboratory services, chest x-ray, routine ECG, and ED visit provided on January 2, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for a knee orthosis with suspension sleeve (L1833, L2397)
provided to the enrollee on December 23, 2019.
You asked the Plan to pay for the orthoses. You say that the claim should be paid. The Plan denied your
request. The Plan says the documentation does not indicate services are necessary for treatment of the
enrollee's condition.
The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when the patient's medical
record contains sufficient documentation of the patient's medical condition to substantiate the necessity for the
type and quantity of items ordered and for the frequency of use.
The record shows that documentation submitted did not indicate the provider discussed the need for the billed
supply code, so the billed supply code cannot be verified. Therefore, we decided that the Plan does not have to
pay for a knee orthosis with suspension sleeve (L1833, L2397) provided to the enrollee on December 23, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the lab services provided on July 30, 2018.
You asked the Plan to pay for the lab services. You say that the lack of timely filing does not constitute
equitable forfeiture. The Plan denied your request. The Plan says the time limit for filing has expired.
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 lab services was not filed until November 15, 2019. 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 lab services provided on July 30, 2018.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the knee orthosis LT, RT (L1851) suspension sleeve RT, LT
(L2397) lumbar sacral orthosis (L0650) provided December 11, 2019.
You asked the Plan to pay for the orthoses. You say that the records should support the necessity of the service
in dispute. The Plan denied your request. The Plan says the records provided do not support the service billed.
The Plan must follow Medicare rules. Medicare rules say that for eligible telehealth services,
telecommunications systems substitute for an in-person encounter. Medicare enrollees are eligible for
telehealth services only if they are presented from an authorized originating site located in either a county
outside of a Metropolitan Statistical Area (MSA) or a rural Health Professional Shortage Area (HPSA) located
in a rural census tract.
A review of the file does not show that the telehealth service was provided in an authorized originating site.
This means that the telehealth visit is not a covered service under the Medicare program and cannot substitute
for an in-person encounter. Consequently, the items/services ordered following the non-covered visit are
likewise non-covered. Therefore, we decided that the Plan does not have to pay for the knee orthosis LT, RT
(L1851) suspension sleeve RT, LT (L2397) lumbar sacral orthosis (L0650) provided December 11, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an additional filling received on January 3, 2020. 
 
You asked the Plan to pre-approve the filling. You say that you disagree with your responsibility. The Plan denied your request. The Plan says the plan has already paid for two fillings. 
 
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, which state that two fillings are covered per year. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the third filling (the one denied in this case) is not a covered benefit. Therefore, we decided that the Plan does not have to pre-approve an additional filling received on January 3, 2020.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pay for the lower extremity study provided on January 29, 2020.
You asked the Plan to pay for the services provided. You say that the enrollee had multiple exams on this date
of service. The Plan denied your request. The Plan says the service was approved and previously paid.
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 93971 is duplex scan of extremity veins including
responses to compression and other maneuvers; unilateral or limited study. The records show that the extremity
study was previously billed and paid for by the Plan. The medical records provided do not show that there was
an additional extremity study provided to the enrollee on the date of service at issue. Based on this information,
we decided that Medicare rules for coverage have not been met. Therefore, we decided that the Plan does not
have to pay for the lower extremity study provided on January 29, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided to the enrollee by an out-ofnetwork
provider on January 6, 2020.
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the 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 services at issue in this appeal. 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 the medical services provided to the enrollee by an out-of-network provider
on January 6, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for a wrist-hand orthosis (L3916) provided to the enrollee on
January 16, 2020.
You asked the Plan to pay for the orthosis. You say that the claim should be paid. The Plan denied your
request. The Plan says the documentation does not indicate services are necessary for treatment of the
enrollee's condition.
The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when the patient's medical
record contains sufficient documentation of the patient's medical condition to substantiate the necessity for the
type and quantity of items ordered and for the frequency of use.
The record shows that documentation submitted did not indicate the provider discussed the need for the billed
supply code, so the billed supply code cannot be verified. Therefore, we decided that the Plan does not have to
pay for a wrist-hand orthosis (L3916) provided to the enrollee on January 16, 2020.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copay for the computed tomography (CT) scan you received on December 21, 2019.
You asked the Plan to waive the copay for the CT scan. You say that you were referred to the facility by your provider. The Plan denied your request. The Plan says the claim processed correctly based on your 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 a $125 copay when advanced imaging services are provided in an outpatient hospital facility.
The file shows that you received a CT scan of the thorax at an outpatient hospital facility. You have been asked to pay $113.21 for the CT scan. Because the amount is less than your $125 copay, you were charged the lesser amount. The CT scan falls within the outpatient diagnostic testing 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 copay for the computed tomography (CT) scan you received on December 21, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay the full cost of deluxe frames (V2025) and progressive lenses (V2781) provided on January 15, 2020. 
 
You asked the Plan to pay the full cost of deluxe frames and progressive lenses. You say that this should be covered. The Plan denied your request. The Plan says this processed correctly according to your benefit. 
 
Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine vision and eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. Although the Plan covers lenses and frames, you are responsible for any amount over $200. 
 
We looked at the file and the Plan's rules. You have been asked to pay $541.60 for lenses and frames. The record shows that the retail price for these items was $877.00. This means you have been asked to pay less than the amount specified in the EOC. Therefore, we decided that the Plan does not have to pay the full cost of deluxe frames (V2025) and progressive lenses (V2781) provided on January 15, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Humalog Kwikpen injection services.
You asked the Plan to pre-approve the Humalog Kwikpen injection services. You say that the chart notes
provided support the need for the drug in dispute. The Plan denied your request. The Plan says the enrollee
does not have a pharmacy benefit with the plan.
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for selfadministered
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 pre-approve Humalog Kwikpen
injection services.
Benefits for the Humalog Kwikpen injection services 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: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission
and services.
You asked the Plan to pre-approve IRF care. You say that the services are necessary. The Plan denied your
request. The Plan says based on the documentation provided, coverage criteria has not been met.
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically
reasonable and necessary as described above.
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 IRF care. Our reviewer says that the
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our
physician reviewer found you do not require the intensity of services provided at an IRF. Specifically, you are
not shown to require fifteen hours per week of rehabilitative services and regular physician evaluation. Your
care needs can be met at a lower level of care.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided to the enrollee by an out-ofnetwork provider on December 26, 2019. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the 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 services at issue in this appeal. 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 the medical services provided to the enrollee by an out-of-network provider on December 26, 2019
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for physician's services provided on February 12, 2020.
You asked the Plan to pay for the physician's services. The Plan denied your request. The Plan says nonemergent,
non-urgent services with out-of-network providers require 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 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 physician's services provided on February 12, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the cost share for the eye exam and the ultrasound of the eye
provided on January 14, 2020.
You asked the Plan to waive the cost share for the eye exam and the ultrasound of the eye. You say that you
were not told there would be an extra charge for the extra scan. The Plan denied your request. The Plan says
you have been charged the correct cost sharing amount.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information. Your
contract with the Plan says that there is a $750 deductible that applies towards ultrasounds, a $35 copayment
for Medicare-covered eye exams to diagnose and treat diseases and conditions of the eye, and a $10 copayment
after the deductible is met for each basic imaging service (e.g., general x-rays or ultrasound).
The ultrasound of the eye you asked the Plan to waive the cost share for falls within the "Outpatient diagnostic
tests and therapeutic services and supplies" benefit category. The eye exam you asked the Plan to waive the
cost share for falls within the "Vision care" benefit category.
The Plan has followed Medicare rules by clearly disclosing in the contract that there is a $750 deductible that
applies towards ultrasounds, a $35 copayment for Medicare-covered eye exams to diagnose and treat diseases
and conditions of the eye, and a $10 copayment after the deductible is met for each basic imaging service (e.g.,
general x-rays or ultrasound).
This cost sharing is a contractual obligation that had not been met at the time the eye exam and the ultrasound
of the eye were received on January 14, 2020. Therefore, we decided that the Plan does not have to waive the
cost share for the eye exam and the ultrasound of the eye provided on January 14, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the services (CPT 93880) provided on January 29, 2020.
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the records only
support one unit of 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.
We find that a second unit of CPT code 93880 is not supported in the medical record. Specifically, the records
provided show that only one unit of CPT 93880 was provided on the date of service in question. The plan has
already paid for one unit of CPT 93880. The records provided do not show that a second unit of CPT 93880
was provided, which means that Medicare coverage criteria have not been met. Therefore, we decided that the
Plan does not have to pay for the services (CPT 93880) provided on January 29, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a leadless pacemaker (33274).
You asked the Plan to pre-approve a leadless pacemaker (33274). You say that the requested leadless
pacemaker is medically necessary. The Plan denied your request. The Plan says per Medicare guidelines,
leadless pacemakers are non-covered when furnished outside of a CMS approved CED study.
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. In this case, Medicare guidelines say leadless pacemakers are noncovered
when furnished outside of a CMS approved CED study. The file does not show that the enrollee is to
have the procedure performed under a CMS approved CED study. Based on this information, we decided that
Medicare rules for coverage of a leadless pacemaker (33274) have not been met. Therefore, we decided that the
Plan does not have to pre-approve a leadless pacemaker (33274).
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the Guardant360 testing rendered on August 3, 2019.
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 the testing is not covered.
The Plan must follow Medicare rules. The rules say that the Guardant360 panel must be billed with procedure
code 81479.
The file shows that the Guardant360 panel was not billed with code 81479 but as a panel of codes. 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 Guardant360 testing rendered on August 3, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Mycophenolate.
You asked the Plan to pre-approve the Mycophenolate. You say that the enrollee has diffuse systemic sclerosis
with lung, kidney, and skin involvement. You say that the drug being requested is medically necessary. The
Plan denied your request. The Plan says the enrollee did not elect to enroll in a prescription drug plan and the enrollee's Part D carrier should be contacted for more information regarding coverage of the
requested drug.
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for selfadministered
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 pre-approve Mycophenolate.
Benefits for the Mycophenolate may be available under Medicare Part D. Contact the Plan that administers Part
D benefits for further information concerning any benefits and appeal rights.