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

 
We decided that the Plan does not have to pay for the eye exam (92014) provided on March 19, 2020, by an out 
of network (OON) provider. 
 
You asked the Plan to pay for eye exam. You say that the services rendered were medically necessary. The 
Plan denied your request. The Plan says prior authorization must be obtained for non-emergent services 
rendered by an out-of-network 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 the eye exam (92014) provided on March 19, 
2020, by an out of network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the standard wheelchair rental and sales tax provided on 
January 15, 2020 by an OON provider. 
 
You asked the Plan to pay for the standard wheelchair rental and sales tax. You say that you had no time for 
your insurance to pre-approve this expense. The Plan denied your request. The Plan says prior authorization 
was not obtained. 
 
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 
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 standard wheelchair rental and sales tax 
provided on January 15, 2020 by an OON provider.
Appeal type: Inpatient Hospital
Decision: Favorable

 
We decided that the Plan has to pay for the chest x-ray (71045) provided. 
 
You asked the Plan to pay for the chest x-ray. You say that you would like reconsideration because the member 
had multiple exams on the same date of service. The Plan denied your request. The Plan says that CPT code 
71045 is a column II code to two column I codes billed by a different provider on the same date of service. 
 
The Plan must follow Medicare rules. Medicare rules say that MACs subject all line items for the same 
beneficiary, same NPI, and same date of service to NCCI edits. 
 
We find that CPT code 71045 is supported in the record. Specifically, the record indicates that CPT code 71045 
was billed by a different provider than who billed the column I codes. NCCI edits do not apply to providers 
with different NPIs. Based on this information, we decided that Medicare rules for coverage of the chest x-ray 
have been met. Therefore, we decided that the Plan has to pay for the chest x-ray (71045) provided.  
 
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: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the vasectomy procedure provided on January 20, 2020. 
 
You asked the Plan to pay for the vasectomy procedure. You say that you would like the Plan to reconsider 
their denial of payment. The Plan denied your request. The Plan says this is not a covered service under 
Medicare or the Plan. 
 
The Plan must follow Medicare rules. The rules say that elective hysterectomy, tubal ligation, and vasectomy, 
if the primary indication for these procedures is sterilization, are not covered. The file shows that you received 
a vasectomy for sterilization purposes. Therefore, we decided that the Plan does not have to pay for the 
vasectomy procedure provided on January 20, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the manual wheelchair (E1161) provided on December 24, 
2019. 
 
You asked the Plan to pay for the manual wheelchair. You say that you would like reconsideration as this 
equipment was billed correctly. The Plan denied your request. The Plan says CPT code E1161 was billed with 
an invalid or missing modifier. 
 
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 CPT code E1161 NUKX is not supported in the record. Specifically, Per CMS, CPT code E1161 
requires modifier RR. This claim was not billed with the appropriate modifier. Based on this information, we 
decided that Medicare rules for coverage of the manual wheelchair have not been met. Therefore, we decided 
that the Plan does not have to pay for the manual wheelchair (E1161) provided on December 24, 2019.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the inpatient hospital stay you had from 
February 27, 2020, to March 2, 2020. 
 
You asked the Plan to waive the copayment for the inpatient hospital stay. You say that you paid your $200 
copayment when you were admitted. The Plan denied your request. The Plan says you were charged this 
copayment 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 per day for days 1-7 for inpatient hospital care.  
 
You have been asked to pay a $200 copayment per day for the inpatient hospital stay. Records show you were 
an inpatient for 4 days, for a total of $800.  This is a per day copayment, not a per admission copayment. 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 inpatient hospital stay you had from February 27, 2020, 
to March 2, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve continued inpatient psychiatric services from October 
21, 2020 onward. 
 
You asked the Plan to pre-approve these services. You say that the enrollee is not able to care for herself and is 
unsafe to return home. The Plan denied your request. The Plan says the services are not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that inpatient psychiatric services may be covered if the 
patient requires active treatment.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve these services. Our reviewer says that 
the services are not medically necessary. Our physician reviewer found the enrollee wad admitted to the 
hospital on October 17, 2020 with unspecified schizophrenia with acute exacerbation. Based on the submitted 
records, it was not expected that she would improve in a reasonable period of time beyond the dates in 
question, as she did not have suicidal or homicidal ideation and had no auditory or visual hallucinations. She is 
cooperative with treatment. It does not appear that active treatment is taking place beyond the dates in question. 
The continued services are not reasonable or medically necessary. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of these services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve continued inpatient psychiatric services from October 21, 2020 onward.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the knee orthosis and suspension sleeve (L1833, L2397) 
provided on March 19, 2020. 
 
You asked the Plan to pay for the knee orthosis and suspension sleeve. You say that you would like 
reconsideration based on the records submitted. The Plan denied your request. The Plan says the documentation 
submitted did not support the diagnosis used on the submitted order, nor did the documentation indicate the 
provider discussed the need for the billed supply code. 
 
The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when there are both a 
physician order and proof of delivery.  
 
The documentation does not contain relevant medical records which support medical necessity for the supplies 
provided in this case. The submitted documentation does not support the diagnosis code on the order. The 
documentation also does not include evidence that the provider discussed the need for the knee orthosis and 
suspension sleeve. The record shows that the Plan made several attempts to obtain the necessary documentation 
without success. Therefore, we decided that the Plan does not have to pay for the knee orthosis and suspension 
sleeve (L1833, L2397) provided on March 19, 2020.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for drug testing. 
 
You asked the Plan to pay for drug test. You say that you are appealing with records. The Plan denied your 
request. The Plan says the denial of payment for this service is correct, because the records indicate that drug 
testing was performed on 19 drug classes which does not support the billing of this code. 
 
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 G0483 is drug test(s), definitive; qualitative or 
quantitative, all sources, includes specimen validity testing, per day; 22 or more drug class(es), including 
metabolites if performed. 
 
We find that CPT code G0483 is not supported in the medical record. Specifically, the records submitted do not 
support that testing was performed on 22 or more drug classes. Based on this information, we decided that 
Medicare rules for coverage of drug test have not been met. Therefore, we decided that the Plan does not have 
to pay for drug testing.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve incontinence supplies. 
 
You asked the Plan to pre-approve incontinence supplies. You say that these are medically necessary. 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 incontinence supplies are not covered 
because they are hygienic items that are non-reusable.  
 
While incontinence supplies may be appropriate in this case, neither the Plan nor Medicare offers coverage of 
these items. Therefore, we decided that the Plan does not have to pre-approve incontinence supplies.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a replacement lightweight manual wheelchair. 
 
You asked the Plan to pre-approve these services. You say that the arms of your current chair are tearing up. 
The Plan denied your request. The Plan says the item is not covered. 
 
The Plan must follow Medicare rules. The rules say that Medicare will replace DME that is irreparably 
damaged and/or has passed the five year reasonable lifetime period. 
 
We looked at the file and Medicare rules. The file does not show that your current wheelchair has exceeded the 
reasonable lifetime period or is irreparably damaged. Based on this information, we decided that Medicare 
rules for coverage of these services have not been met. Therefore, we decided that the Plan does not have to 
pre-approve a replacement lightweight manual wheelchair.
Appeal type: SNF
Decision: Favorable

We decided that the Plan has to pay for the skilled nursing facility (SNF) services provided from May 1, 2020 
to May 24, 2020. 
 
You asked the Plan to pay for the SNF services. The Plan denied your request. The Plan says that the enrollee 
no longer required daily skilled from either a nurse or therapist. 
 
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 provided sufficient medical records showing that the services were not necessary for the dates 
of service at issue. The documentation does not include notification that SNF services would no longer be 
covered. The Plan has not made reasonable and diligent efforts to gather and forward to us information 
regarding their decision to deny your request. Therefore, we decided that the Plan has to pay for the skilled 
nursing facility (SNF) services provided from May 1, 2020 to May 24, 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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a battery pack (E1399). 
 
You asked the Plan to pre-approve a battery pack. You say that this is necessary for use with the enrollee's 
continuous positive airway pressure device. 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 battery pack (E1399).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve drug eluting implant (Dextenza) (0356T). 
 
You asked the Plan to pre-approve the Dextenza. You say that Medicare has completed their review of this 
procedure and added it to their list of approved codes. The Plan denied your request. The Plan says this service 
is experimental and investigational. There is no clear evidence to support improved outcomes. This procedure 
does not have enough proof to support the safety and success of its use. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered. The rules also say that experimental and investigational devices are not covered. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the Dextenza have not been met. Therefore, we decided that the Plan does not have to pre-approve 
drug eluting implant (Dextenza) (0356T).
Appeal type: Transportation
Decision: Favorable

We decided that the Plan has to pre-approve ambulance transportation for dialysis treatments. 
 
You asked the Plan to pre-approve the ambulance transportation. The Plan denied your request. The Plan says 
that the services are not medically necessary. 
 
Medicare pays for ambulance services only when they are medically reasonable and necessary. The Plan 
follows the same rules.  
 
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 ambulance transportation. Our 
reviewer says that the requested ambulance services are medically reasonable and necessary. Our physician 
reviewer found that the submitted documentation supports need for ambulance transport for dialysis treatments. 
 
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 ambulance transportation have been met. Therefore, we decided that the 
Plan has to pre-approve ambulance transportation for dialysis treatments.  
 
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: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve endovenous ablation. 
 
You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied 
your request. The Plan says the services are not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that endovenous ablation is covered when specific 
criteria are 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 pre-approve these services. Our reviewer says that 
the services are not medically necessary. Our physician reviewer found the submitted records do not not 
satisfactorily describe symptoms attributable to varicose veins that are creating lifestyle limiting symptoms that 
are resistant to conservative treatments. There is no documentation that the enrollee has tried and failed 
concerted efforts at conservative treatment. .  There is documentation of consideration of what appears to be 
seven procedures in a patient that appears to already be status post treatment of both greater saphenous and 
both small saphenous veins. These additional procedures even include consideration of treating a vein without 
reported reflux. There is no evidence of active or healed ulceration. The requested procedure is not reasonable 
or medically necessary. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of these services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve endovenous ablation.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for the non-emergent transportation you received from June 5, 
2020, to July 3, 2020. 
 
You asked the Plan to pay for the transportation. The Plan denied your request. The Plan says this is not a 
covered benefit. 
 
The Plan must follow Medicare rules. Medicare does not cover transport in a vehicle that is not an ambulance. 
The Plan follows the same rule.  
 
We looked at your request, the records in the case file, and the rules. Based on this information, we decided 
that the Medicare rules for coverage of the transportation have not been met. Therefore, we decided that the 
Plan does not have to pay for the non-emergent transportation you received from June 5, 2020, to July 3, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the dental services that you provided from February 6, 2020, 
to February 21, 2020. 
 
You asked the enrollee's Plan to pay for the dental services provided from February 6, 2020, to February 21, 
2020. You say that you knew you were participating with the dental Plan. You say that after providing 
multiple services you realized you were not participating with the enrollee's specific plan. You also say that this 
was not the enrollee's fault and he is an elderly man on a fixed income. The Plan denied your request. The Plan 
says you are not a participating provider. The Plan says services obtained from a non-participating provider 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 enrollee's Plan offers a dental benefit in excess of Medicare coverage, the requested items or 
services are not among those covered under this benefit when provided by a non-participating provider. 
Therefore, we decided that the Plan does not have to pay for the dental services that you provided from 
February 6, 2020, to February 21, 2020.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the abdominal ultrasound provided on March 31, 2020 by an 
out of network (OON) provider. 
 
You asked the Plan to pay for the OON services. You say that the services were clinically appropriate and 
medically necessary. The Plan denied your request. The Plan says the enrollee could have received the services 
from an in-network 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 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 abdominal ultrasound provided on March 31, 2020 by an out of network (OON) 
provider.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the physical therapy services (97112, 97116, 97163, 97110, 
97530) provided on April 16, 2020 to April 30, 2020 by an out of network (OON) provider. 
 
You asked the Plan to pay for OON physical therapy services. You say that these services were medically 
necessary. The Plan denied your request. The Plan says these services were not authorized. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The requested provider in this case is not a network provider with the Plan. The Plan has network providers 
available who can provide the items/services at issue in this appeal. The Plan did not pre-approve the 
item/service at issue. We found no exception that would require the Plan to pay for these items/services. 
Therefore, we decided that the Plan does not have to pay for the physical therapy services (97112, 97116, 
97163, 97110, 97530) provided on April 16, 2020 to April 30, 2020 by an out of network (OON) provider.