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

 
We decided that the Plan does not have to pay for a back brace (L0650) provided on February 18, 2020. 
 
You asked the Plan to pay for a back brace. You say that this was medically necessary. The Plan denied your 
request. The Plan says the enrollee did not present from an authorized originating site and this brace was 
prescribed in a soliciting call. 
 
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 a back brace (L0650) 
provided on February 18, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the medical services provided on April 29, 2019 by an out of 
network (OON) provider. 
 
You asked the Plan to pay for office visit. You say that the Plan should allow coverage for this visit. The Plan 
denied your request. The Plan says the denial of payment for this service is correct, because this provider is 
out-of-network with the Plan and 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 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 medical services provided on April 29, 2019 
by an out of network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the pathology services provided on September 24, 2019 by 
an out of network (OON) provider. 
 
You asked the Plan to pay for the OON pathology services. You say that this testing was necessary after being 
examined by a network provider. The Plan denied your request. The Plan says neither the ordering provider nor 
the laboratory are in-network with this Plan. No authorization was requested for either service. As such, the 
denial is correct in this case. 
 
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 pathology services provided on September 24, 
2019 by an out of network (OON) provider.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a knee injection with FlowerAmnioFlo. 
 
You asked the Plan to pre-approve the injection. You say that you would like reconsideration because you have 
knee pain and would like to try this therapy. The Plan denied your request. The Plan says you do not have an 
approved indication for this type of therapy. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for a drug or biological only if it is safe 
and effective and otherwise reasonable and 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 injection. Our reviewer says that 
there is a lack of evidence to support the use of Amniotic fluid derivatives in patients with knee osteoarthritis 
and chronic knee pain. Our physician reviewer found the Medicare criteria of this service being medically 
reasonable and necessary is not met. 
 
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 injection have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a knee injection with FlowerAmnioFlo.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an inpatient hospital stay provided from 
May 19, 2020 to May 21, 2020. 
 
You asked the Plan to waive the copayment for an inpatient hospital stay. You say that you disagree with the 
charges because you had to be readmitted shortly after your discharge. The Plan denied your request. The Plan 
says the claims were processed correctly and you are being charged the correct 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 a $325 
copayment for inpatient hospital care.  
 
You have been asked to pay a $325 copayment for an inpatient hospital stay. An inpatient hospital stay falls 
within the inpatient hospital care 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 inpatient hospital stay provided from May 19, 2020 to May 21, 2020.  
 
Your quality-of-care concerns have been handled separately by the health plan.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for ankle-foot orthotics provided on February 20, 2020. 
 
You asked the Plan to pay for ankle-foot orthotics. You say that you are appealing with supporting records. The 
Plan denied your request. The Plan says the denial of payment for these items is correct, because the 
documentation does not support a face-to-face evaluation, physical examination, or imaging and the enrollee's 
geographical area is not eligible for telehealth services. 
 
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 ankle-foot orthotics 
provided on February 20, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the proton beam therapy rendered on September 12, 2019. 
 
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 is a duplicate. 
 
The Plan must follow Medicare rules. The rules say that claims or claim lines that have been determined to be 
exact duplicates of another claim or claim line are denied. 
 
We looked at the file and Medicare rules. The file shows that the services at issue were previously paid by the 
Plan on a separate claim for the same date of service. 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 proton beam therapy rendered on September 12, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve meal delivery services. 
 
You asked the Plan to pre-approve these services. You say that your current body mass index (BMI) is 27 or 
higher. The Plan denied your request. The Plan says you do not meet the criteria for coverage. 
 
The Plan must follow Medicare rules. Medicare rules say that meal delivery services are not covered. The Plan 
contract says that up to 16 meals per qualifying event are covered, allows up to four events each calendar year 
(64 meals in total). 
 
We looked at the file and the Plan?s rules. The file shows that you have a BMI of 27 or higher but do not meet 
the Plan?s other criteria for coverage of these services. Therefore, we decided that the Plan does not have to 
pre-approve meal delivery services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the powered upper extremity range of motion assist 
device, elbow, wrist, hand, finger, single or double upright(s), includes microprocessor, sensors, all 
components and accessories, custom fabricated (L8702) for the enrollee. 
 
You asked the Plan to pre-approve the DME. You say that the DME is medically necessary. The Plan denied 
your request. The Plan says medical studies have not provide that the device(s) is helpful for treatment of the 
enrollee's health problem. 
 
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 DME. Our reviewer says that the 
requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found myoelectric orthosis devices are often recommended for amputation or congenital absence of a 
limb, however, there is insufficient high quality supportive evidence available for this device in the setting of 
hemiplegia following stroke. Available evidence on this device included case reports and low number studies 
only. Based on the poor quality of evidence currently available to support this device for this clinical situation, 
this request for such will be considered not medically 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 DME have not been met. Therefore, we decided that the Plan does not have 
to pre-approve the powered upper extremity range of motion assist device, elbow, wrist, hand, finger, single or 
double upright(s), includes microprocessor, sensors, all components and accessories, custom fabricated 
(L8702) for the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for physician's services provided on December 26, 2019. 
 
You asked the Plan to pay for the physician's services. The Plan denied your request. The Plan says the Plan 
requires utilization of network providers when possible and available, and requires authorization for certain 
services. No medical necessity for an out-of-network provider, such as an urgent or emergency situation, has 
been documented. 
 
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 
physician?s services. 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 physician's services provided on December 26, 2019.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayments for the ultrasounds provided on January 8, 
2020. 
 
You asked the Plan to waive the copayments for the diagnostic and transvaginal ultrasounds. You say that the 
ultrasounds were a part of the wellness exam. The Plan denied your request. The Plan says you were charged 
the copayments 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 $110 
copayment for radiological diagnostic services.  
 
You have been asked to pay $110 copayment for the ultrasounds. The ultrasounds fall within the radiological 
diagnostic 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 copayments for the ultrasounds 
provided on January 8, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve electric seat lift mechanism (E0627). 
 
You asked the Plan to pre-approve the electric seat lift mechanism. You say that you are requesting review of 
denial of services. The Plan denied your request. The Plan says you drive a car and enter and exit the car 
without assistance, so you do not meet any of the established criteria. 
 
The Plan must follow Medicare rules. The rules say that a seat lift mechanism is covered if all of the conditions 
listed above 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 the electric seat lift mechanism. Our 
physician reviewer found the patient appears to have arthritis, however, the notes are not clear enough to show 
evidence from imaging or physical examination findings of severe arthritis of the hip or neuromuscular disease. 
The notes provided did not show documentation of the treating physician recommending a seat lift. Based on 
the notes suggesting insufficient sit to stand dysfunction, the seat lift is not likely to significantly improve the 
patient?s condition and will not slow deterioration of the patient?s condition. The records do not show that the 
patient is completely incapable of standing from a chair in the home. The records show that the patient has the 
ability ambulate with the assistance of a cane. 
 
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 electric seat lift mechanism have not been met. Therefore, we decided that 
the Plan does not have to pre-approve electric seat lift mechanism (E0627).
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pay for 3 units of aminophylline. 
 
You asked the Plan to pay for 3 units of aminophylline (J0280). You say that the Plan should pay this claim. 
The Plan denied your request. The Plan says that the documentation submitted does not support the units billed. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report the actual number of units 
provided for each procedure code. 
 
We find that 3 units of CPT code J0280 are supported in the medical record. The provider had submitted 
updated medical notes. Based on this information, we decided that Medicare rules for coverage of 3 units of 
aminophylline (J0280) have been met. Therefore, we decided that the Plan has to pay for 3 units of 
aminophylline.  
 
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again 
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake 
and/or send us the new information. This does not happen often. If we decide to open the case again, we will 
send you a letter.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an electrocardiogram (93010) provided on February 26, 
2020. 
 
You asked the Plan to pay for the electrocardiogram. You say that you would like reconsideration based on the 
records submitted. The Plan denied your request. The Plan says the record does not include documentation of 
an interpretation by the rendering provider. 
 
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 93010 is electrocardiogram, routine ECG with at least 12 
leads; interpretation and report only. 
 
We asked our coder 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 electrocardiogram. Our reviewer says that CPT code 
93010 does not meet criteria for billing or reimbursement consideration. Our reviewer found the documentation 
submitted does not include an interpretation report. 
 
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 electrocardiogram have not been met. Therefore, we decided that the Plan 
does not have to pay for an electrocardiogram (93010) provided on February 26, 2020.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an ultrasound provided on February 19, 
2020. 
 
You asked the Plan to waive the copayment for an ultrasound. You say that you disagree with the charges 
because you should have a $0 copayment for radiology services. The Plan denied your request. The Plan says 
the claims were processed correctly and you are being charged the correct 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 a $0 
copayment for each diagnostic mammogram and a $75 copayment for each radiological diagnostic service.  
 
You have been asked to pay the allowed amount of $58.14, which is less than the $75 copayment for an 
ultrasound. An ultrasound falls within the outpatient diagnostic tests and therapeutic services and supplies 
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 ultrasound provided on 
February 19, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the breast thermography provided on March 5, 2020. 
 
You asked the Plan to pay for the thermography. You say that you believe this was denied due to a billing 
error. You were told by two different representatives that this could be done in place of a mammogram and it 
would be covered. The Plan denied your request. The Plan says call history was reviewed and there is no 
evidence of a call to the Plan prior to this service in which you asked about coverage for this imaging or where 
you were told it was covered. The only call is from after the test when reimbursement documents were 
requested. 
 
The Plan must follow Medicare rules. Medicare rules say that thermography is nationally non-covered for all 
indications. Therefore, we decided that the Plan does not have to pay for the breast thermography provided on 
March 5, 2020.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a CT Scan of the thorax (71250). 
 
You asked the Plan to pre-approve the CT Scan. You say that you would like reconsideration based on the 
records submitted. The Plan denied your request. The Plan says this service is not medically necessary. 
 
The Plan follows Medicare rules. Medicare rules say that beneficiaries must be between 55 and 77 years old. 
 
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 CT Scan. Our reviewer says that the 
NCD for coverage for lung cancer screening with low dose computed tomography (LDCT) (210.14) stipulates 
that patients are between 55 and 77 years old. Our physician reviewer found the enrollee is 82 and therefore not 
included in the covered population. 
 
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 CT Scan have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a CT Scan of the thorax (71250).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the services provided from February 3, 2020 through March 
3, 2020 by a non-Medicare provider. 
 
You asked the Plan to pay for the services. You say that this provider does not accept or file for any medical 
insurance. The Plan denied your request. The Plan says the provider has opted out of Medicare participation. 
The Plan contacted this provider's office who had you sign a form notifying you that the provider 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. This 
provider has opted out of the Medicare program. Therefore, we decided that the Plan does not have to pay for 
the services provided from February 3, 2020 through March 3, 2020 by a non-Medicare provider.