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

 
We decided that the Plan does not have to pay for the face-down positioning table (E1399) purchased February 
12, 2020. 
 
You asked the Plan to pay for the face-down positioning table. You say that you had paid the provider directly 
and had also called the plan ahead of time and was told it was covered. Please reconsider. The Plan denied your 
request. The Plan says this item is a precautionary device and can also be used for purposes other than the 
treatment of an illness or injury. 
 
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 pay for the face-down positioning table (E1399) purchased February 12, 
2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the debridement services (11042) and the office visit (99213) 
rendered by the out of network (OON) provider on February 10, 2020. 
 
You asked the Plan to pay for these services. You say that you are requesting a reconsideration of the Plan's 
denial for payment. The Plan denied your request. The Plan says the services were rendered by an out of 
network provider, without 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 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 debridement services (11042) and the office visit (99213) rendered by the out of 
network (OON) provider on February 10, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve medical nutrition therapy; initial assessment and 
intervention (97802) to be provided by an out of network (OON) provider. 
 
You asked the Plan to pre-approve medical nutrition therapy services. You say that you had gastric bypass 
surgery and has an eating disorder and you really need to see this nutritionist. The Plan denied your request. 
The Plan says enrollee's must receive their medical services from an in-network provider. The plan says that 
non-emergent services with non-contracted providers require prior-authorization prior to services being 
rendered 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pre-approve care from out-of-network providers only in cases involving 
emergencies, out of area urgent care and care that cannot be provided by network providers. 
 
The requested provider in this case is not a network provider with the Plan. The Plan has network providers 
available who can provide the items/services at issue in this appeal. We found no exception that would require 
the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve 
medical nutrition therapy; initial assessment and intervention (97802) to be provided by an out of network 
(OON) provider.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pay for amoxicillin (D9630) provided on February 16, 2020. 
 
You asked the Plan to pay for amoxicillin. You say that this should be paid. The Plan denied your request. The 
Plan says coverage of this medication is the responsibility of your prescription drug plan. 
 
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-
administered 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 pay for amoxicillin (D9630) provided on 
February 16, 2020.  
 
Benefits for amoxicillin 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: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a maxillary partial denture. 
 
You asked the Plan to pre-approve the maxillary partial denture. You say that you need the partial denture so 
that you are able to eat. The Plan denied your request. The Plan says this service is only covered 1 time in a 60 
month time period. The Plan also says that you have already received this service during this time period. 
 
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, dentures are limited to 1 every 5 years. 
The record shows that you received a maxillary partial denture on January 28, 2019 and your denture benefit 
has been exhausted. Therefore, we decided that the Plan does not have to pre-approve a maxillary partial 
denture.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for outpatient hospital services provided on December 2, 2019 through December 20, 2019.
You asked the Plan to pay for the outpatient services. You say that you would like reconsideration based on the records submitted. The Plan denied your request. The Plan says HCPCS code 9099 is a non-allowed service under OPPS and HCPCS A4657 is a packaged item into APC rates.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the outpatient services have not been met. Specifically, per the Hospital Outpatient PPS, CPT code 90999 has a status indicator of B. This means that this code is not recognized by OPPS when submitted on an outpatient hospital Part B bill type (12x and 13x). This claim was submitted with type of bill code 137. Payment for this service may not be made under OPPS. CPT code A4567 has a status indicator of N. This means that payment for CPT code A4567 is packaged into payment for other services. Therefore, we decided that the Plan does not have to pay for outpatient hospital services provided on December 2, 2019 through December 20, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to preapprove a pneumatic compression device (E0652). 
 
You asked the Plan to preapprove a pneumatic compression device. You say that the enrollee requires the 
device. The Plan denied your request. The Plan says the documentation did not support the 4-week trial using 
the basic pump that Medicare requires. 
 
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 preapprove a pneumatic compression device 
(E0652).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for the chemotherapy drug provided on March 
14, 2019. 
 
You asked the Plan to waive the coinsurance for the chemotherapy drug. You say that you met your out-of-
pocket maximum in June 2019 and that the provider billed untimely. The Plan denied your request. The Plan 
says the claim was reprocessed and 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 (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay 20% 
coinsurance for Part B drugs, including chemotherapy drugs.  
 
You have been asked to pay $1,111.89 coinsurance for the chemotherapy drug, which is less than the standard 
20% coinsurance amount. The chemotherapy drug falls within the Medicare Part B prescription drugs benefit 
category. The record shows that since this claim was reprocessed, your maximum out-of-pocket amount was 
also reprocessed. Therefore, you had not met your maximum out-of-pocket amount.  
 
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 coinsurance for the chemotherapy drug provided on March 14, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the assistant surgeon services during arthroplasty services provided on August 14, 2019.
You asked the Plan to pay for the assistant surgeon services. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the services billed are not payable.
The Plan follows Medicare rules. The rules say that Medicare only pays for assistant surgery services when the procedure is covered for an assistant and the person who assists the surgery bears the designation of a physician, PA, NP, or CNS. In this case, the record does not show that the provider of the surgical assistant service is a physician, PA, NP, or CNS. Medicare only makes payment for surgical assistant services when provided by one of these types of practitioners. Therefore, we decided that the Plan does not have to pay for the assistant surgeon services during arthroplasty services provided on August 14, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve four periodontal scalings and root plannings.
You asked the Plan to pre-approve the scalings and plannings. The Plan denied your request. The Plan says this
service exceeds the benefit allowance.
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, periodontal scaling and root planing is
limited to once every 24 months. The record shows that you received four periodontal scalings and root
plannings on July 22, 2019 and your periodontal scalings and root plannings benefit has been exhausted.
Therefore, we decided that the Plan does not have to pre-approve four periodontal scalings and root plannings.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a K3 lower limb prosthesis (L5981, L5986).
You asked the Plan to pre-approve the prosthesis. You say that the prosthesis is medically necessary. The Plan
denied your request. The Plan says this type of prosthesis exceeds the enrollee's functional needs.
The Plan follows Medicare rules. Medicare rules say that this type of prosthesis is covered for beneficiaries
whose functional level is 3 or 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 the prosthesis. Our reviewer says that
the requested type of prosthesis is not medically necessary. Our physician reviewer found an advanced K3
lower limb prosthesis is requested. The enrollee's functional status is not well documented so the need for the
advanced features cannot be determined.
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 prosthesis have not been met. Therefore, we decided that the Plan does not
have to pre-approve a K3 lower limb prosthesis (L5981, L5986).
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for transportation of a portable x-ray (R0070) provided on 
March 26, 2020. 
 
You asked the Plan to pay for the transportation of a portable x-ray. You say that you would like 
reconsideration based on the records submitted. The Plan denied your request. The Plan says CPT code R0070 
has a Professional Component (PC)/Technical Component (TC) indicator of 3 per the January 2020 National 
Physician Fee Schedule Relative Value File. 
 
The Plan must follow Medicare rules. Medicare rules say that if the patient is in a Part A SNF stay, the 
transportation and set up costs are subject to consolidated billing and not separately billable to Medicare Part B. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the transportation of a portable x-ray have not been met. Specifically, this claim has been billed 
with place of service code 31, which indicates that the member was in a Part A SNF stay. This means that this 
service is subject to consolidated billing and not separately billable to Medicare Part B. Therefore, we decided 
that the Plan does not have to pay for transportation of a portable x-ray (R0070) provided on March 26, 2020.
Appeal type: Surgery
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 21, 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 was a mandatory service. The Plan denied your request. The Plan says payment for this 
service. 
 
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 21, 2020.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the Guardant360 panel rendered on February 25, 2020. 
 
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says the claim was not billed correctly. 
 
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 panel rendered on February 25, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Dexcom G6 sensor. 
 
You asked the Plan to pre-approve the sensor. You say that this is medically necessary. The Plan denied your 
request. The Plan says the Dexcom G6 is the non-preferred monitor. 
 
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 sensor. Our reviewer says that the 
requested sensor is not considered medically reasonable and necessary in this case. Our physician reviewer 
found there is no evidence that the enrollee has used the health plan's preferred CGM and been unsuccessful 
with or intolerant of the device.  There is no clear documentation as to why the requested meter is necessary 
over the health plan's preferred meter.  The documentation does not currently show that the requested meter is 
medically necessary and reasonable. 
 
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 sensor have not been met. Therefore, we decided that the Plan does not have 
to pre-approve a Dexcom G6 sensor.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the Guardant360 testing provided on February 18, 2020. 
 
You asked the Plan to pay for the Guardant360 testing. You say that you would like the plan to reconsider their 
denial. The Plan denied your request. The Plan says the services rendered are not billed correctly. 
 
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 the Guardant360 testing is not supported in the medical record. Specifically, 
precertification/authorization/notification is not provided on the submitted claim. Based on this information, we 
decided that Medicare rules for coverage of the Guardant360 testing have not been met. Therefore, we decided 
that the Plan does not have to pay for the Guardant360 testing provided on February 18, 2020.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pay for medical nutrition therapy (G0270) provided from January 9, 
2020 to January 15, 2020. 
 
You asked the Plan to pay for medical nutrition therapy. You say that this was medically necessary. The Plan 
denied your request. The Plan says this is not covered for the enrollee's condition. 
 
The Plan must follow Medicare rules. Medicare rules say that medical nutrition therapy services are covered 
for certain beneficiaries who have diabetes or a renal disease. 
 
We looked at the file and Medicare rules. The record does not show that the enrollee had diabetes or renal 
disease. Based on this information, we decided that Medicare rules for coverage of medical nutrition therapy 
have not been met. Therefore, we decided that the Plan does not have to pay for medical nutrition therapy 
(G0270) provided from January 9, 2020 to January 15, 2020.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a percutaneous laminotomy/laminectomy for the
enrollee.
You asked the Plan to pre-approve the services. You say that this is medically necessary. The Plan denied your
request. The Plan says this is covered by Medicare in the setting of a clinical trial.
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 services. Our reviewer says that the
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer
found the enrollee presents with complaints of low back pain with occasional radiation into the left lower
extremity. She is reported to have neurogenic claudication symptoms. There is imaging evidence of moderate
to severe central canal stenosis, moderate lateral recess stenosis, and moderate bilateral foraminal narrowing at
the L4/5 level with ligamentum flavum hypertrophy. She underwent an L4/5 lumbar interlaminar epidural
steroid injection, with excellent relief for 4 weeks. Under consideration is a request for the MILD (minimally
invasive lumbar decompression) procedure at the L4/5. There is current evidence based medical literature
support for the use of this procedure for the treatment of spinal stenosis, as compared to lumbar epidural steroid
injection. However, in this case, there are no clinical exam findings documented and no clear discussion to
support the medical necessity of minimally invasive surgery over standard lumbar decompression (in this
setting of moderate to severe multifactorial stenosis which typically cannot be fully addressed with minimally
invasive surgery.) Therefore, this request for percutaneous laminotomy/laminectomy (MILD procedure) would
not be considered medically reasonable and necessary at this time.
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 services have not been met. Therefore, we decided that the Plan does not
have to pre-approve a percutaneous laminotomy/laminectomy for the enrollee.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an outpatient surgery provided by a 
participating provider on March 6, 2020. 
 
You asked the Plan to waive the copayment for an outpatient surgery. You say that you don't think that you 
should have to pay two $325 copayments. The Plan denied your request. The Plan says the correct copayment 
has been applied. 
 
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 $325 
copayment for outpatient surgery.  
 
You have been asked to pay a $325 copayment for an outpatient surgery. The correct copayment has been 
applied to the services that were provided. An outpatient surgery falls within the outpatient surgery benefit 
category. This means that you have been asked to pay the correct amount based on your contract with the Plan. 
This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we 
decided that the Plan does not have to waive the copayment for an outpatient surgery provided by a 
participating provider on March 6, 2020.