Persius/hicric huggingface dataset:
Appeal type: Inpatient Hospital
Decision: Favorable

 
We decided that the Plan has to pay for acute inpatient hospital provided on July 13, 2020, through July 22, 
2020. 
 
You asked the Plan to pay for acute inpatient hospital. You say that the readmission could not have been 
prevented. The Plan denied your request. The Plan says that the readmission was preventable and conservative 
management could have been considered which may not have required inpatient hospitalization. 
 
The Plan follows Medicare rules. Medicare rules say that readmission review involves admissions to an acute, 
general, short-term hospital occurring less than 31 calendar days from the date of discharge from the same or 
another acute, general, short-term hospital. Neither the day of discharge nor the day of admission is counted 
when determining whether a readmission has occurred. 
 
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 acute inpatient hospital. Our reviewer says 
that the service is not medically necessary. Our physician reviewer found the documentation indicates that the 
small bowel obstruction was resolved at the time of discharge on July 9, 2020 and the readmission did not 
result from a premature discharge from the same hospital. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of acute inpatient hospital have been met. Therefore, we decided that the Plan has 
to pay for acute inpatient hospital provided on July 13, 2020, through July 22, 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: Step-Therapy
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the Synvisc-One (J7325) and injection (20610) provided on 
May 11, 2020. 
 
You asked the Plan to pay for the Synvisc-One and injection. The Plan denied your request. The Plan says no 
prior authorization was requested, and there was no evidence that the enrollee had tried and failed a trial of 
Orthovisc and Monovisc. The Plan also says that the provider has not stated that Orthovisc and Monovisc 
would not be as effective or would have adverse effects. 
 
Medicare covers Part B medications when they are reasonable and necessary but allows health plans to 
implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain 
Part B medications. 
 
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 Synvisc-One and injection. Our 
reviewer says that the Synvisc-One and injection are not medically reasonable and necessary for the enrollee. 
Our physician reviewer found the available documentation does not support that the enrollee tried and failed 
Orthovisc and Monovisc. Our reviewer also found that the documentation does not support that Orthovisc and 
Monovisc would likely have been less effective, and/or would likely have had adverse effects for the enrollee 
in this case. 
 
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 Synvisc-One and injection have not been met. Therefore, we decided that 
the Plan does not have to pay for the Synvisc-One (J7325) and injection (20610) provided on May 11, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for specialist services provided on August 5, 2020 by an out of 
network (OON) provider. 
 
You asked the Plan to pay for specialist services. You say that you would like this claim reprocessed and 
approved for payment. The Plan denied your request. The Plan says prior authorization was not obtained. The 
Plan says that the referring provider is also out-of-network. 
 
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 specialist services provided on August 5, 2020 by 
an out of network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the CardioMEMs device (CPT Codes: C2624 and 
33289). 
 
You asked the Plan to pre-approve the CardioMEMs device. You say that the services are necessary. The Plan 
denied your request. The Plan says the services are considered experimental/investigational and are not covered 
by Medicare. 
 
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 CardioMEMs device. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found in this circumstance, therapy change based on data obtained from a CardioMEMs 
device has been demonstrated in only one randomized prospective trial to help reduce hospital readmission 
compared to standard medical therapy. Moreover, concerns have been raised about potential bias in this trial 
calling into question the results. Therefore, the efficacy of the CardioMEMS device is uncertain at this time 
according to leading authorities and not recommended in current guidelines for the treatment of heart failure. 
Medicare coverage criteria are not met, in my opinion, since the device should still be considered experimental 
or investigational. 
 
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 CardioMEMs device have not been met. Therefore, we decided that the Plan 
does not have to pre-approve the CardioMEMs device (CPT Codes: C2624 and 33289).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services provided on September 2, 2020. 
 
You asked the Plan to pay for the laboratory services. 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 a covered benefit. 
 
The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few 
tests listed above, are not covered. 
 
The laboratory testing at issue in this appeal was requested solely for screening purposes. Medicare does not 
cover this test solely for screening purposes. Therefore, we decided that the Plan does not have to pay for the 
laboratory services provided on September 2, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for eye refraction services (92015) provided on August 4, 2020. 
 
You asked the Plan to pay for the eye refraction services. You say that this service was medically necessary 
and would like this claim reprocessed and approved for payment. The Plan denied your request. The Plan says 
these services are not covered. 
 
Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine 
vision and eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in 
this case. The Plan covers these services when they are performed during a routine eye exam. 
 
We looked at the file and the Plan's rules. The file indicates that you received the eye refraction services during 
a medical eye exam and not a routine eye exam. Based on this information, we decided that the Plan's rules for 
coverage of the eye refraction services have not been met. Therefore, we decided that the Plan does not have to 
pay for eye refraction services (92015) provided on August 4, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the telemedicine services received on April 16, 2020. 
 
You asked the Plan to pay for the telemedicine services. You say that you would like the plan to reconsider 
their denial. The Plan denied your request. The Plan says the services received are not payable. 
 
The Plan must follow Medicare rules. The rules state that Medicare plans are considered secondary insurers 
when an enrollee has another type of insurance. This means that the Plan is not responsible for paying for 
services until the claim for those services has gone to the primary insurer. However, plans are still required to 
coordinate their benefits with the primary insurers. Plans can coordinate their benefits with the primary insurers 
in three ways. First, the Plan can send the bill directly to the primary insurer for payment. Second, the Plan can 
direct the provider to send the bill to the primary insurer. Third, the Plan can pay for the services and submit a 
bill for reimbursement to the primary insurer. 
 
The Plan has met its obligation with regards to coordination of benefits. Specifically, the Plan has directed the 
provider to send the bill to the primary insurer. As the secondary insurer, the Plan cannot be held responsible 
for the telemedicine services until the primary insurer has denied the claim for these services. Review of the 
file shows that the services received were for a recurrent workers compensation issue. Therefore, we decided 
that the Plan does not have to pay for the telemedicine services received on April 16, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the complete maxillary denture and complete mandibular 
denture provided on August 24, 2020. 
 
You asked the Plan to pay for the complete maxillary denture and complete mandibular denture. You say that 
you accidentally broke your dentures, and had a letter from the Plan saying you had a $700 allowance for 
dental services. The Plan denied your request. The Plan says the dental provider who rendered these services 
has opted out of Medicare. 
 
The Plan must follow Medicare rules. The rules say that no Medicare payment may be made to a beneficiary 
for items or services provided directly by a physician or practitioner who has opted out of the program except 
in cases involving emergencies or urgently needed care. 
 
The services at issue in this appeal were provided in a non-urgent, non-emergent situation by the provider who 
has opted out of the Medicare program. Therefore, we decided that the Plan does not have to pay for the 
complete maxillary denture and complete mandibular denture provided on August 24, 2020.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an ambulance transport (A0427) provided 
on August 5, 2020. 
 
You asked the Plan to waive the copayment for an ambulance transport. You say that you should not have to 
pay for the ambulance transport. The Plan denied your request. The Plan says the correct copayment was 
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 $200 
copayment for ambulance services.  
 
You have been asked to pay a $200 copayment for an ambulance transport. The services at issue fall within the 
ambulance services 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 ambulance 
transport (A0427) provided on August 5, 2020.  
 
Your complaint about your physician insisting you use an ambulance transport is not a valid appeal for medical 
coverage. This part of your complaint is a grievance that must be answered by the Plan. Medicare does not 
permit us to make a decision about these types of complaints.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the new patient assisted living visit (99328) and 
comprehensive assessment of and care planning (G0506) provided on August 10, 2020 by an out of network 
(OON) provider. 
 
You asked the Plan to pay for the new patient assisted living visit and comprehensive assessment of and care 
planning. You say that the services provided were medically necessary. The Plan denied your request. The Plan 
says prior authorization was not obtained by the facility or the provider; therefore, payment has been correctly 
denied. 
 
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 new patient assisted living visit (99328) and 
comprehensive assessment of and care planning (G0506) provided on August 10, 2020 by an out of network 
(OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for monitored anesthesia care provided on July 13, 2020. 
 
You asked the Plan to pay for monitored anesthesia care. You say that monitored anesthesia care was necessary 
for the enrollee's extreme anxiety. The Plan denied your request. The Plan says the service was not medically 
necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered. Medicare rules say that providers must produce medical records to support the 
services billed.  
 
We looked at file and Medicare rules. In this case, there were insufficient records provided to support the 
service billed. Based on this information, we decided that Medicare rules for coverage of monitored anesthesia 
care have not been met. Therefore, we decided that the Plan does not have to pay for monitored anesthesia care 
provided on July 13, 2020.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the magnetic resonance imaging (MRI) scan of leg joint 
(73721). 
 
You asked the Plan to pre-approve the MRI scan of leg joint. You say that this service is medically necessary. 
The Plan denied your request. The Plan says you do not meet the criteria for the MRI. 
 
The Plan must follow Medicare rules. Medicare rules say that MRIs are covered only when they are 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 MRI scan of leg joint. Our reviewer 
says that the service is not medically necessary. Our physician reviewer found the plan requires new symptoms 
to qualify for a cross sectional imaging study in a patient with a benign nerve sheath tumor, and this patient has 
no new such symptoms. In addition, the chart note on November 12, 2020 describes a plan for a computed 
tomography (CT) scan rather than MRI of the left foot. For the above reasons the medical necessity of MRI of 
the left foot has not been established as the patient has no new symptoms and the biopsy proven tumor was 
benign and deemed unresectable. 
 
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 MRI scan of leg joint have not been met. Therefore, we decided that the 
Plan does not have to pre-approve the magnetic resonance imaging (MRI) scan of leg joint (73721).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to preapprove wheelchair components defined by codes E2300, E2377, 
E2313, E2311. 
 
You asked the Plan to preapprove the wheelchair components. You say that the power mobility device and all 
the components are necessary. The Plan denied your request. The Plan says the power wheelchair is covered, 
but the specified options and accessories are not. 
 
The Plan follows Medicare rules. Medicare rules say requested the additional components are to control power 
tilt, recline and power elevating leg rests through the joystick. The notes state that these are needed when 3 or 
more actuators are being used. The electrical connection between the wheelchair controller and two or more 
motors (E2311), expandable controller (E2377) and harness (E2313) cannot be covered.  
 
The file shows that there is not a medical need to control these power options through the joystick. The enrollee 
has 3-4/5 upper extremity strength and is independent with grooming, hygiene and feeding. Member's upper 
limb strength and function are adequate for the member to be able to control the power options using their own 
switches which are included in the allowance of these power options.  This means that Medicare rules for 
coverage of the additional components have not been met. Therefore, we decided that the Plan does not have to 
preapprove wheelchair components defined by codes E2300, E2377, E2313, E2311.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a pneumatic compression device (E0676). 
 
You asked the Plan to pay for a pneumatic compression device. You say that this was medically necessary. The 
Plan denied your request. The Plan says this is not covered. 
 
The Plan follows Medicare rules. The rules state that a PCD that provides intermittent limb compression for the 
purpose of prevention of venous thromboembolism (E0676) is a preventive service. 
 
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, this item is not a covered benefit of Medicare or the Plan. 
This item is used for a preventative service and is excluded from Medicare coverage. Therefore, we decided 
that the Plan does not have to pay for a pneumatic compression device (E0676).
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for portable x-ray services (HCPCS Q0092 and R0070) provided 
to the enrollee on August 30, 2020. 
 
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. 
The Plan says when the enrollee is under an approved SNF stay, the provider should reimbursement from the 
SNF directly. 
 
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 the denied codes is: 
 
HCPCS Q0092: 
 
Set-up portable x-ray equipment 
 
HCPCS R0070: 
 
Transportation of portable X-ray equipment and personnel to home or nursing home, per trip to facility or 
location, one patient seen 
 
 
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 
services at issue in this case were not supported by the medical records. Our coding reviewer found these 
services do not meet the criteria and should not be billed separately. 
 
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 portable x-ray services (HCPCS Q0092 and R0070) provided to the enrollee on August 30, 
2020.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for two ambulance trips provided on August 
27, 2020. 
 
You asked the Plan to waive the copayment for two ambulance trips. You say that you should not be charged 
because you did not choose to be transported. The Plan denied your request. The Plan says you were charged 
this cost sharing 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 $225 
copayment for each ambulance trip. You had two ambulance trips. The Plan charged you $550 for these 
services. 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 two ambulance trips provided on August 27, 
2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a percutaneous diskectomy (62287) performed on May 29, 
2020. 
 
You asked the Plan to pay for a percutaneous diskectomy. You say that you were not informed of any 
requirement for Medicare participation. The Plan denied your request. The Plan says rules for payment have 
not been met. 
 
The rules state that no provider or supplier shall receive payment for services furnished to a Medicare 
beneficiary unless the provider or supplier is enrolled in the Medicare program. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the hospital services have not been met. Specifically, the services at issue were provided by a 
provider that appears to not be certified for Medicare. The provider at issue did not come up on the 
Medicare.gov search for hospital providers serving the enrollee's area. There was no documentation supplied 
by the provider to verify that they are certified by Medicare. Based on this information, we decided that 
Medicare rules for coverage of a percutaneous diskectomy have not been met. Therefore, we decided that the 
Plan does not have to pay for a percutaneous diskectomy (62287) performed on May 29, 2020.