Persius/hicric huggingface dataset:
Appeal type: Outpatient Therapies
Decision: Favorable

We decided that the Plan has to waive the additional copayment applied to the application of a multi-layer 
compression system to the leg during an occupational therapy visit provided on December 16, 2019 billed with 
code 29581-GO. 
 
You asked the Plan to waive the additional copayment applied to the compression system application. You say 
that it is felt that an additional copayment is not appropriate as this compression wrapping is a part of the 
occupational therapy plan of care and is billed as such. The Plan denied your request. The Plan says that a 
specialist service copayment was correctly applied to code 29581. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). The enrollee's contract with the Plan says that enrollees must pay a 
$40 copayment for Medicare-covered occupational therapy visits. 
 
The Plan says the enrollee must pay an additional $45 copayment for specialist services provided on this date 
of service. However, based on the contract, the enrollee cannot be asked to pay more than a $40 copayment for 
a single occupational therapy visit. The code 29581 was billed with a GO modifier indicating it was performed 
as part of the occupational therapy plan of care. There is no language in the contract which would create a 
reasonable expectation that an additional copayment would be applied to a service provided during an 
occupational therapy visit. There is likewise no evidence to support applying a specialist copayment to this 
service as it appears this care would have been rendered by the same provider who performed the manual 
therapy. Therefore, we decided that the Plan has to waive the additional copayment applied to the application 
of a multi-layer compression system to the leg during an occupational therapy visit provided on December 16, 
2019 billed with code 29581-GO.  
 
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 an oximeter and blood pressure monitor (E0445, A4670 and 
99199) provided on April 3, 2020. 
 
You asked the Plan to pay for the oximeter. You say that you would like reconsideration based on the records 
submitted. The Plan denied your request. The Plan says this service is not a covered benefit. 
 
The Plan must follow Medicare rules.  
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the oximeter have not been met. Specifically, the oximeter is not a covered benefit of Medicare or 
the Plan. There is no evidence that you have suspected white coat hypertension to be considered for coverage 
of the blood pressure monitor. Therefore, we decided that the Plan does not have to pay for an oximeter and 
blood pressure monitor (E0445, A4670 and 99199) provided on April 3, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the services (J7328) provided on February 27, 2020. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the billed 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 J7328 is "Hyaluronan or derivative, gelsyn-3, for intra-
articular injection, 0.1 mg". 
 
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 use 
of code J7328 is not supported by the records provided. Our coding reviewer found that the procedure report 
did not include dosage administered. Therefore, the number of units is not supported. 
 
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 the services (J7328) provided on February 27, 2020.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a referral out of plan for ultrasound guided 
sclerotherapy (UGS) treatments and an office visit. 
 
You asked the Plan to pre-approve the referral. You say that you would like reconsideration because you have 
been receiving these injections since 2019. The Plan denied your request. The Plan says this service is not 
medically indicated. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the referral. Our reviewer says that the 
requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found there is not satisfactory documentation that you are having lifestyle limitations due to spider 
veins. Additionally, it is unclear if there is a recent evaluation of lower extremity arterial perfusion.  There is 
inadequate documentation of concerted efforts at conservative treatment being attempted recently. 
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 referral have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a referral out of plan for ultrasound guided sclerotherapy (UGS) treatments and an office 
visit.
Appeal type: Outpatient Therapies
Decision: Favorable

We decided that the Plan has to waive the additional copayment applied to the application of a multi-layer 
compression system to the leg during an occupational therapy visit provided on February 4, 2020 billed with 
code 29581-GO. 
 
You asked the Plan to waive the additional copayment applied to the compression system application. You say 
that it is felt that an additional copayment is not appropriate as this compression wrapping is a part of the 
occupational therapy plan of care and is billed as such. The Plan denied your request. The Plan says that a 
specialist service copayment was correctly applied to code 29581. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). The enrollee's contract with the Plan says that enrollees must pay a 
$40 copayment for Medicare-covered occupational therapy visits. 
 
The Plan says the enrollee must pay an additional $45 copayment for specialist services provided on this date 
of service. However, based on the contract, the enrollee cannot be asked to pay more than a $40 copayment for 
a single occupational therapy visit. The code 29581 was billed with a GO modifier indicating it was performed 
as part of the occupational therapy plan of care. There is no language in the contract which would create a 
reasonable expectation that an additional copayment would be applied to a service provided during an 
occupational therapy visit. There is likewise no evidence to support applying a specialist copayment to this 
service as it appears this care would have been rendered by the same provider who performed the manual 
therapy. Therefore, we decided that the Plan has to waive the additional copayment applied to the application 
of a multi-layer compression system to the leg during an occupational therapy visit provided on February 4, 
2020 billed with code 29581-GO.  
 
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: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ambulance services provided on 
December 3, 2020. 
 
You asked the Plan to pay for the ambulance services. You say that you were trying to save money. 
The Plan denied your request. The Plan says these services are not a covered benefit. 
 
The Plan must follow Medicare rules. The rules say that Medicare does not pay for ambulance services when 
there is no transport.  
 
The ambulance company did not provide transport services on December 3, 2019. The ambulance benefit is a 
transportation benefit. When there is no transport, neither Medicare nor the Plan pays for the services provided. 
Therefore, we decided that the Plan does not have to pay for the ambulance services provided on December 3, 2020.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for hormone pellet implantation (11980) provided on April 20, 
2020. 
 
You asked the Plan to pay for the hormone pellet implantation. You say that you would like reconsideration 
because this service is medically necessary and has been covered in the past. The Plan denied your request. The 
Plan says this service is considered experimental. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pay for the hormone pellet implantation. Our 
reviewer says that the requested items/services are not considered medically reasonable and necessary in this 
case. Our physician reviewer found there are potential risks associated with androgen replacement, and the use 
of testosterone is limited by the lack of approved and commercially available products for women. Until the 
beneficial effects of androgen replacement are better established, it cannot be routinely recommended to 
postmenopausal women. 
 
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 hormone pellet implantation have not been met. Therefore, we decided that 
the Plan does not have to pay for hormone pellet implantation (11980) provided on April 20, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for knee orthosis (L1851), ankle foot orthosis (L1971), 
suspension sleeve (L2397), heel stabilizer (L3170), wrist hand orthosis (L3916) and shoulder elbow wrist hand 
orthosis (L3960) provided on March 11, 2020. 
 
You asked the Plan to pay for the orthoses. You say that you would like reconsideration because this equipment 
was medically necessary. The Plan denied your request. The Plan says  
 
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 record does not contain a valid proof of delivery for the supplies provided in this case. Specifically, the 
record does not include an itemized billing/shipping invoice or proof of delivery to verify the supplies billed. 
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 knee orthosis (L1851), ankle foot orthosis 
(L1971), suspension sleeve (L2397), heel stabilizer (L3170), wrist hand orthosis (L3916) and shoulder elbow 
wrist hand orthosis (L3960) provided on March 11, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the knee orthosis (L1833) provided April 10, 2020. 
 
You asked the Plan to pay for the orthosis. You say that kindly find the attached medical records that prove the 
medical necessity and reprocess the claim. The Plan denied your request. The Plan says all information was 
provided over the phone. The orthoses provided were not shown to be needed for treatment of degenerative 
disease or specific instability or deformity confirmed by actual medical records from the enrollee's historical 
treating providers. The documentation does not identify the enrollee's originating site at the time of the 
telehealth visit. 
 
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 noncovered visit are 
likewise noncovered. Therefore, we decided that the Plan does not have to pay for the knee orthosis (L1833) 
provided April 10, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the assembly and operation of a pump with an oxygenator or 
heat exchanger (99190) provided on March 25, 2020. 
 
You asked the Plan to pay for the assembly and operation of a pump with an oxygenator or heat exchanger. 
You say that this should be covered. The Plan denied your request. The Plan says payment for this service is 
included in the DRG. 
 
The Plan must follow Medicare rules. The rules say that there is no payment under the OPPS for services that 
CMS designates to be "inpatient-only" services. These services have an OPPS status indicator of "C" in the 
OPPS Addendum B and are listed together in Addendum E of each year's OPPS/ASC final rule.  
 
The service at issue in this appeal was billed with CPT code 99190. This code is listed with a status indicator of 
"C" on Addendum B of the 2020 OPPS/ASC final rule. This means the service has been designated as 
"inpatient only", and therefore must be billed as part of an inpatient admission. Therefore, we decided that the 
Plan does not have to pay for the assembly and operation of a pump with an oxygenator or heat exchanger 
(99190) provided on March 25, 2020.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Vertiflex Superion Spacer. 
 
You asked the Plan to pre-approve the device. You say that you would like reconsideration because this 
procedure is medically necessary. The Plan denied your request. The Plan says this device is experimental. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the device. Our reviewer says that the 
requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found FDA contraindications include osteoporosis, and have not been adequately addressed in the 
medical records. Superion indirect lumbar decompression would not be considered the standard of care for the 
enrollees medical condition. 
 
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 device have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Vertiflex Superion Spacer.
Appeal type: DME/ Orthotics
Decision: Favorable

We decided that the Plan has to pre-approve power wheelchair accessories (expandable controller, harness, 
electrical connection). 
 
You asked the Plan to pre-approve the accessories. You say that this is medically necessary. The Plan denied 
your request. The Plan says that this is not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that if there are no specific coverage rules for an item 
or service, then that item or service will be covered when it is medically necessary.  
 
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 accessories. Our reviewer says that 
the requested accessories are considered medically reasonable and necessary in this case. Our physician 
reviewer found you are very weak and would benefit from these easier controls. In addition, you are at risk for 
decubiti. The accessories are appropriate and 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 accessories have been met. Therefore, we decided that the Plan has to pre-
approve power wheelchair accessories (expandable controller, harness, electrical connection).  
 
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: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services for the 
enrollee. 
 
You asked the Plan to pre-approve the LTACH services. You say that these services are medically necessary. 
The Plan denied your request. The Plan says that the member's current needs are being met in the acute 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. The patient 
is currently undergoing treatment at an acute care hospital (ACH) following a motor vehicle collision, resulting 
in multiple and serious brain injuries and thoracic injuries. The enrollee was intubated/ventilated upon 
presentation and subsequently received a tracheotomy. The enrollee has been weaned from the ventilator. The 
enrollee's mental status remains poor and it seems unlikely that she will be decannulated. 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 needs. Our physician reviewer 
found that the enrollee's condition does not meet Medicare criteria for LTACH 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 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 for the enrollee.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) admission and services. 
 
You asked the Plan to pre-approve SNF services. You say that you have had multiple falls at home. The Plan 
denied your request. The Plan says you have not had a change in function that requires daily skilled therapy or 
nursing needs. 
 
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 services. Our physician reviewer 
found that you were treated in the hospital for acute kidney injury, hypomagnesemia, diarrhea and hepatic 
encephalopathy. You are walking 250 feet with a wheeled walker with stand-by assistance, at modified 
independence for transfers, and at supervision to moderate assist for activities of daily living. You are 
medically stable. There is no documentation that you require the specialized skill of a skilled professional nurse 
to safely and effectively provide medically necessary treatment. You do not require skilled therapy services of 
a qualified therapist to safely and effectively provide medically necessary treatment. Daily skilled services are 
not required. Therefore, the enrollee does not require skilled services on 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 services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve skilled nursing facility (SNF) admission and services.