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

 
We decided that the Plan does not have to provide a pneumatic compression device (E0652). 
 
You asked the Plan to provide a pneumatic compression device. You say that the enrollee has tried 
conservative treatment and a regular pump. The Plan denied your request. The Plan says the records do not 
show the enrollee has had a 4 week trial with a basic pump. 
 
The Plan follows Medicare rules. The rules state that a PCD coded as E0652 is covered for the treatment of 
lymphedema extending onto the chest, trunk and/or abdomen after a four-week trial of conservative therapy 
 
 
demonstrating failed response to treatment with an E0650 or E0651. At least four weeks of regular, daily, 
multiple-hour home usage of the E0650 or E0651 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, daily, multiple-hour home usage of the E0650 or E0651 after careful, in-person fitting, 
training and supervision by a technician who is skilled in and who regularly and successfully uses the appliance 
provided. Therefore, we decided that the Plan does not have to provide a pneumatic compression device 
(E0652).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a walk-in bathtub. 
 
You asked the Plan to pre-approve a walk-in bathtub. You say that this is medically necessary. The Plan denied 
your request. The Plan says that this is considered a convenience item primarily hygienic in nature and thus not 
covered. 
 
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a 
medical purpose.   
 
The item at issue in this appeal does not serve a purpose that is primarily medical in nature. This item is 
available to the general public and would be helpful even to those who are not sick or injured. Therefore, we 
decided that the Plan does not have to pre-approve a walk-in bathtub.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve therapy services to be provided by an out of network 
provider. 
 
You asked the Plan to pre-approve the out of network therapy services. You say that you want to see the out-of-
network provider. The Plan denied your request. The Plan says they have in-network providers that can provide 
therapy services. 
 
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 services at issue in this appeal. We found no exception that would require the 
Plan to pre-approve these services. Therefore, we decided that the Plan does not have to pre-approve therapy 
services to be provided by an out of network provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a heavy duty walker (E0149) and walker seat 
attachment (E0156). 
 
You asked the Plan to pre-approve a heavy duty walker and walker seat attachment. You say that the items are 
necessary. The Plan denied your request. The Plan says the enrollee has similar equipment. Therefore, coverage 
criteria has not been met. 
 
The Plan must follow Medicare rules. The rules say Medicare covers DME only when it is reasonable and 
necessary. If DME serves the same purpose as equipment already available to an enrollee, it is not considered 
reasonable and necessary. 
 
The file shows that the enrollee has a regular walker. A regular walker serves the same purpose as a heavy duty 
walker and walker seat attachment. Therefore, we decided that the Plan does not have to pre-approve a heavy 
duty walker (E0149) and walker seat attachment (E0156).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for sedation services (99152) provided. 
 
You asked the Plan to pay for sedation services. You say that this was billed correctly. The Plan denied your 
request. The Plan says this code is not supported. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
In this case, the CPT Code Manual definition of code 99152 is moderate sedation services provided by the 
same physician or other qualified health care professional performing the diagnostic or therapeutic service that 
the sedation supports, requiring the presence of an independent trained observer to assist in the monitoring of 
the patient's level of consciousness and physiological status; initial 15 minutes of intraservice time, patient age 
5 years or older. 
 
We find that CPT code 99152 is not supported in the medical record. Specifically, the submitted medical 
records do not include documentation of an independent trained observer. Based on this information, we 
decided that Medicare rules for coverage of sedation services have not been met. Therefore, we decided that the 
Plan does not have to pay for sedation services (99152) provided.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a complete maxillary and mandibular partial denture 
and 14 extractions. 
 
You asked the Plan to pre-approve the services. You say that this is medically necessary, as you are unable to 
eat. The Plan denied your request. The Plan says the benefit has been exhausted for the 2020 plan year. 
 
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, the requested items or services are not 
among those covered under this benefit. The records show that an extraction was already approved for 11/2/20. 
The additional 14 extractions are beyond the plan's benefit. The dentures are not listed as a covered benefit. 
Therefore, we decided that the Plan does not have to pre-approve a complete maxillary and mandibular partial 
denture and 14 extractions.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for out of network physician services provided on July 28, 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 the enrollee did not have prior authorization for out of network care. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. The provider 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 out of network physician 
services provided on July 28, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit (92014) and aflibercept injection (J0178) 
provided on July 9, 2020. 
 
You asked the Plan to pay for the office visit and aflibercept injection. You say that you should not be 
responsible for the charges. The Plan denied your request. The Plan says based on Medicare billing criteria, the 
claim was billed 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 $35 
copayment for each Medicare-covered specialist visit and 20% co-insurance for covered drugs. 
 
You have been asked to pay $407.71 ($35 + $372.71) for the office visit and aflibercept injection. 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 pay for an office visit (92014) and aflibercept injection (J0178) provided on July 9, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the initial periapical x-ray (D0220), the additional periapical 
x-ray (D0230), and the unspecified preventive service (D1999) provided on July 22, 2020. 
 
You asked the Plan to pay for the dental services. You say that you have the dental coverage now. You also say 
that this was medically necessary. The Plan denied your request. The Plan says periapical x-rays are not listed 
as a covered service. The Plan says the unspecified periapical x-ray is not listed as a covered service either. The 
Plan also says you were not enrolled in the additional supplemental dental rider on the date of service. 
 
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, the x-rays and unspecified preventive 
service are not among those covered under this benefit. Although the x-rays you received are listed as covered 
under the additional supplemental dental rider, coverage under the dental rider was not effective until August 1, 
2020. Therefore, we decided that the Plan does not have to pay for the initial periapical x-ray (D0220), the 
additional periapical x-ray (D0230), and the unspecified preventive service (D1999) provided on July 22, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a personal emergency response system for the enrollee. 
 
You asked the Plan to pre-approve the system. You say that this is medically necessary. The Plan denied your 
request. The Plan says this is not a covered benefit. 
 
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a 
medical purpose.   
 
The item at issue in this appeal does not serve a purpose that is primarily medical in nature. This item is 
available to the general public and would be helpful even to those who are not sick or injured. Therefore, we 
decided that the Plan does not have to pre-approve a personal emergency response system for the enrollee.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Keytruda for the enrollee. 
 
You asked the Plan to pre-approve Keytruda. You say that this is medically necessary. The Plan denied your 
request. The Plan says that the clinical value and effectiveness of Keytruda in the setting of non-small cell lung 
cancer (NSCLC) with unknown PD-L1 status have not been demonstrated in the peer-reviewed literature. 
 
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 Keytruda. Our reviewer says that 
Keytruda is not medically reasonable and necessary for the enrollee in this case. The requested use of Keytruda 
is not FDA approved. The requested use of Keytruda is not supported in any of the CMS approved compendia. 
There are no PubMed citations supporting the use in cancers with unknown PDL1 expression. The use of 
Keytruda is not listed as not indicated, not supported or not recommended in any of the compendia. Our 
physician reviewer found that the enrollee's condition does not meet Medicare criteria for coverage of 
Keytruda. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Keytruda have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Keytruda for the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit provided on March 3, 2020 by an out of 
network (OON) provider. 
 
You asked the Plan to pay for an office visit. You say that you would like this claim reprocessed and approved 
for payment. The Plan denied your request. The Plan says prior authorization was obtained. The Plan says that 
there is no referring provider. 
 
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 an office visit provided on March 3, 2020 by an 
out of network (OON) provider.
Appeal type: Lab
Decision: Favorable

 
We decided that the Plan has to waive the copayment for lab services provided on July 6, 2020. 
 
You asked the Plan to waive the copayment for lab services. You say that you disagree with the charges 
because you have no record of being at any facility on this date of service. The Plan denied your request. The 
Plan says that the claims were processed correctly and you are being charged the correct amount. 
 
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and 
diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or 
payment. 
 
The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their 
decision to deny your request. The Plan did not provide medical records. Without medical records we cannot 
determine whether or not services took place. Therefore, we decided that the Plan has to waive the copayment 
for lab services provided on July 6, 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: Hospice
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the initial hospital care and subsequent hospital care 
provided from November 15, 2019, to November 30, 2019. 
 
You asked the Plan to pay for the initial hospital care and subsequent hospital care. 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 enrollees terminal condition. 
 
Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice 
services. Original Medicare is responsible for payment for services until the first day of the month after the 
hospice election has been revoked or terminated. 
 
The enrollee ended Medicare Hospice benefits on November 11, 2019. The services in question were provided 
before the end of that month. Therefore, we decided that the Plan does not have to pay for the initial hospital 
care and subsequent hospital care provided from November 15, 2019, to November 30, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve facet joint injections (64493, 64494). 
 
You asked the Plan to pre-approve the injections. You say that the injections are medically necessary. The Plan 
denied your request. The Plan says coverage criteria has not been met. 
 
The Plan follows Medicare rules. Medicare rules say that facet joint injections are covered when medically 
necessary and the pain is not associated with radiculopathy. 
 
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 injections. Our reviewer says that 
the requested injections are not medically necessary. Our physician reviewer found the enrollee is positive for 
radiculopathy at L4-S1. The MRI shows multiple sources of pain. There is no current physical exam since 
6/2019 to identify the facet joint as the source of pain. 
 
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 injections have not been met. Therefore, we decided that the Plan does not 
have to pre-approve facet joint injections (64493, 64494).
Appeal type: Hospice
Decision: Unfavorable

We decided that the Plan does not have to pay for hospital care (99233) provided on March 30, 2020.
You asked the Plan to pay for hospital care. You say that this claim does not fall within the date range of the
patient's enrollment in hospice care. The Plan denied your request. The Plan says rules for payment have not
been met.
Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice
services. Original Medicare is responsible for payment for services until the first day of the month after the
hospice election has been revoked or terminated.
The enrollee ended Medicare Hospice benefits on March 13, 2020. The services in question were provided
before the end of that month. Therefore, we decided that the Plan does not have to pay for hospital care (99233)
provided on March 30, 2020.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pay for the radiology services provided on March 26, 2019.
You asked the Plan to pay for the radiology services. You say that your records indicate that the claim was filed
timely. The Plan denied your request. The Plan says the claim was untimely.
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 radiology services was not filed until July 30, 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 radiology services provided on March 26, 2019.
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pay for the intravenous (IV) hydration provided during an outpatient hospital 
visit on May 19, 2020. 
 
You asked the Plan to pay for the IV hydration services. You say that this code should be paid as it was 
medically necessary. The Plan denied your request. The Plan says that the fluid used to administer the drug(s) 
is incidental hydration and is not separately payable. Therefore, this was correctly denied. 
 
The Plan must follow Medicare rules. Medicare rules say that hydration codes are used to report IV infusion of 
normal saline or electrolyte solutions. Fluid used to administer drugs is not separately payable as it is 
considered incidental hydration. 
 
In this case, there is no indication that this IV saline was administered as part of an IV infusion of any drug. No 
drugs were billed on this claim and the records do not indicate that any drugs were administered through IV. 
The records do support that IV hydration was provided. The billed code is correct and appropriate to report IV 
hydration when not used in the administration of any other drugs/substances. The Plan's rationale is directly 
negated by the Medicare rules and the file. Therefore, we decided that the Plan has to pay for the intravenous 
(IV) hydration provided during an outpatient hospital visit on May 19, 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: ER
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the ER visit provided on August 17, 2020. 
 
You asked the Plan to waive the copayment for the ER visit. You say that there were no after hours at the 
doctor's office available, so you had to go to the ER. You say that the copayment should be $0. 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 $120 
copayment for emergency care.  
 
You have been asked to pay $100.14, which is less than the standard $120 copayment for the ER visit. The ER 
visit falls within the "Emergency care" benefit category. The records show that you were seen in the ER to fix 
your catheter. 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 ER visit provided on August 17, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the electrocardiogram services coded 93010 provided on 
June 29, 2020. 
 
You asked the Plan to pay for the electrocardiogram 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 separately 
payable. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. In this case, we have confirmed that code 93010 
for the electrocardiogram services has a bundled relationship with code 93280 and cannot be paid as billed. 
This code cannot be paid as a separate line item. Based on the claim submitted, Medicare billing criteria have 
not been met. Therefore, we decided that the Plan does not have to pay for the electrocardiogram services 
coded 93010 provided on June 29, 2020.