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

 
We decided that the Plan does not have to pre-approve 200 One Touch Ultra Blue test strips per 30 days. 
 
You asked the Plan to pre-approve the 200 test strips. You say that you would like reconsideration because the 
additional test strips are medically necessary. The Plan denied your request. The Plan says proof of medical 
necessity to make an exception to the benefit was not provided by your prescribing physician. 
 
The Plan must follow Medicare rules. Medicare rules say that to consider coverage and payment for any item 
or service, the information submitted by the supplier or provider must corroborate the documentation in the 
beneficiary's medical documentation and confirm that Medicare coverage criteria have been met. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the 200 test strips have not been met. Specifically, per Medicare's LCD up to 100 lancets every 3 
months are covered for enrollees who are not currently being treated with insulin. The record does not indicate 
why it is a medically necessary requirement for the member to receive more than the Medicare and Plan benefit 
allowance. Therefore, we decided that the Plan does not have to pre-approve 200 One Touch Ultra Blue test 
strips per 30 days.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a shower chair. 
 
You asked the Plan to pre-approve a shower chair. You say that the requested item is necessary for the enrollee. 
You asked the Plan to reconsider providing coverage for the requested item. The Plan denied your request. The 
Plan says this item is not a covered benefit. 
 
The Plan must follow Medicare rules. Medicare rules say that shower chairs are not covered because they are 
not primarily medical in nature.  
 
While a shower chair may be appropriate in this case, neither the Plan nor Medicare offers coverage of this 
item. Therefore, we decided that the Plan does not have to pre-approve a shower chair.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a white cane for use by a blind person.
You asked the Plan to pre-approve a white cane. You say that your last cane only lasted 6 months and you do
not want to have be required to depend on your wife. The Plan denied your request. The Plan says a white cane
for use by a bind person is more of an identifying and self-help device and is not covered by Medicare.
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a
medical purpose.
The item at issue in this appeal does not serve a purpose that is primarily medical in nature. This item is
available to the general public and would be helpful even to those who are not sick or injured. Therefore, we
decided that the Plan does not have to pre-approve a white cane for use by a blind person.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the POV, group 1 heavy duty, patient weight capacity 
301 to 450 pounds (K0801). 
 
You asked the Plan to pre-approve the POV. You say that the POV is medically necessary. The Plan denied 
your request. The Plan says you have previously received the same items within the 5-year RUL. 
 
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 POV have not been met. Review of the records show that you 
were approved for a heavy-duty Group 1 POV with weight capacity of 301-450 pounds on May 1, 2018. The 
Plan contacted the supplier and was advised that it was delivered to you on May 4, 2018. The Plan states that 
there was an authorization for POV repairs approved on July 20, 2020. Medicare does not pay for duplicate 
equipment that performs the same function as previously provided equipment and does not cover additional 
equipment for use outside of the home. The rules state that equipment which the enrollee owns or is a capped 
rental item may be replaced in cases of loss or irreparable damage. Irreparable damage refers to a specific 
accident or to a natural disaster (e.g., fire, flood). A physicians order and/or new Certificate of Medical 
Necessity (CMN), when required, is needed to reaffirm the medical necessity of the item. Irreparable wear 
refers to deterioration sustained from day-to-day usage over time and a specific event cannot be identified. 
Replacement of equipment due to irreparable wear takes into consideration the reasonable useful lifetime of the 
equipment. If the item of equipment has been in continuous use by the enrollee on either a rental or purchase 
basis for the equipments useful lifetime, the enrollee may elect to obtain a new piece of equipment. 
Replacement may be reimbursed when a new physician order and/or new CMN, when required, is needed to 
reaffirm the medical necessity of the item. The reasonable useful lifetime of durable medical equipment is 
determined through program instructions. In the absence of program instructions, A/B MACS (B) may 
determine the reasonable useful lifetime (RUL) of equipment, but in no case can it be less than 5 years. 
Therefore, we decided that the Plan does not have to pre-approve the POV, group 1 heavy duty, patient weight 
capacity 301 to 450 pounds (K0801).
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a Freestyle Libre 14 day sensor and reader. 
 
You asked the Plan to pay for the sensor. You say that you would like reconsideration because this sensor and 
reader is medically necessary. The Plan denied your request. The Plan says the documentation submitted does 
not indicate that the member requires twice a day blood glucose monitoring. 
 
The Plan follows Medicare rules. Medicare rules say that therapeutic CGMs and related supplies are covered 
by Medicare when specific criteria are met.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pay for the sensor. Our reviewer says that the 
member does not meet LCD criteria for coverage. Our physician reviewer found the documentation does not 
show how many shots of insulin the member takes and why glucomenters have not worked in the past. 
 
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 pay for a Freestyle Libre 14 day sensor and reader.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for a shoulder-hand-wrist orthosis (L3960) and a knee orthosis
with suspension sleeve (L1833, L2397) provided to the enrollee on December 4, 2019.
You asked the Plan to pay for the orthoses. You say that the claim should be paid. The Plan denied your
request. The Plan says the documentation does not indicate services are necessary for treatment of the
enrollee's condition.
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 shoulder-hand-wrist
orthosis (L3960) and a knee orthosis with suspension sleeve (L1833, L2397) provided to the enrollee on
December 4, 2019.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pre-approve home health services.
You asked the Plan to pre-approve the services. You say that this is medically necessary. The Plan denied your
request. The Plan says the information received did not show documentation that the requested 27 skilled
nursing visits were medically necessary and reasonable.
The Plan must follow Medicare rules. The rules say that home health care services may be covered if it is
medically necessary for the enrollee to receive skilled nursing or therapy. A doctor must certify the need for
home health care services.
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 medically reasonable or necessary. Our physician reviewer found you do not require
skilled nursing or rehab services to effectively provide treatment, care, and/or services to improve your
condition, perform a maintenance program to maintain your condition and/or prevent deterioration.
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 home health services.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a chiropractic office visit received on February 10, 2020. 
 
You asked the Plan to pay for the services. You say that while on vacation, you developed pain in your lower 
back and legs so severe that you could only walk 30 to 40 yards without having to sit and rest. The Plan denied 
your request. The Plan says the plan only covers manual manipulation of the spine to correct subluxation. 
 
The Plan must follow Medicare rules. The rules say that the only chiropractic service Medicare covers is 
manual manipulation of the spine to correct a subluxation.  
 
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 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 services have not been met. Therefore, we decided that the Plan does not 
have to pay for a chiropractic office visit received on February 10, 2020.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the drug testing coded 80307 and G0482 provided on August 
19, 2019. 
 
You asked the Plan to pay for the drug testing. 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 supported by the documentation. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
We find that CPT codes 80307 and G0482 are not supported in the medical record. Specifically, the 
documentation does not support any evidence of an established relationship between the enrollee and the 
ordering physician. Based on this information, we decided that Medicare rules for coverage of the drug testing 
have not been met. Therefore, we decided that the Plan does not have to pay for the drug testing coded 80307 
and G0482 provided on August 19, 2019.
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to waive the deductible for the insertion of a catheter provided on January 14, 
2020. 
 
You asked the Plan to waive the deductible for the insertion of a catheter. You say that you cannot afford the 
charges. The Plan denied your request. The Plan says that 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. Your 
contract with the Plan says that enrollees must pay a $200 deductible. The deductible does not apply to 
outpatient surgery services.   
 
The Plan says you must pay a $200 deductible for the insertion of a catheter. Based on the Plan contract, 
however, you cannot be asked to pay a deductible for outpatient surgery services. Therefore, we decided that 
the Plan has to waive the deductible for the insertion of a catheter provided on January 14, 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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an orthosis (HCPCS L3960) provided to the enrollee on 
February 23, 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 the documentation submitted did not indicate that the provider discussed the need for the billed 
supply code. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
In this case, the CPT Code Manual definition of HCPCS code L3960 is "SEWHO, abduction positioning, 
airplane design, prefabricated, includes fitting and adjustment." 
 
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 the 
documentation did not include a detailed physician's order to include: type of durable medical equipment 
needed, quantity and frequency or replacement, and diagnosis. The documentation also did not include a proof 
of delivery to include: patient name and address, medical equipment with quantity and patient or patients 
beneficiary designee signature and date received, to verify the medical equipment was delivered. 
 
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 an orthosis (HCPCS L3960) provided to the enrollee on February 23, 2020.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the drug testing coded G0483 provided on October 24, 2019. 
 
You asked the Plan to pay for the drug testing. 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 supported by the documentation. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
In this case, the CPT Code Manual definition of code G0483 is drug test(s), definitive, utilizing (1) drug 
identification methods able to identify individual drugs and distinguish between structural isomers (but not 
necessarily stereoisomers), including, but not limited to gc/ms (any type, single or tandem) and lc/ms (any type, 
single or tandem and excluding immunoassays (e.g., ia, eia, elisa, emit, fpia) and enzymatic methods (e.g., 
alcohol dehydrogenase)), (2) stable isotope or other universally recognized internal standards in all samples 
(e.g., to control for matrix effects, interferences and variations in signal strength), and (3) method or drug-
specific calibration and matrix-matched quality control material (e.g., to control for instrument variations and 
mass spectral drift); qualitative or quantitative, all sources, includes specimen validity testing, per day; 22 or 
more drug class(es), including metabolite(s) if performed. 
 
We find that CPT code G0483 is not supported in the medical record. Specifically, the submitted 
documentation did not contain sufficient detail to support the billed charges. The place of service on the CMS-
1500 form line 24B must reflect the location of the patient when the specimen was obtained. The submitted 
claim form indicates the laboratory specimen was obtained in a laboratory, place of service 11; however, the 
submitted medical documentation and/or claim history indicates that the specimen was obtained in an 
outpatient rehabilitation setting place of service 57. Based on this information, we decided that Medicare rules 
for coverage of the drug testing have not been met. Therefore, we decided that the Plan does not have to pay for 
the drug testing coded G0483 provided on October 24, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the Guardant360 testing provided on March 16, 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 were billed incorrectly. 
 
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, this service should be 
billed with code 81479. In addition, the appropriate DEX Z code identifier should be put adjacent to the CPT 
code in the comment/narrative field. 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 March 16, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the drug testing coded 80307 provided on August 6, 2019.
You asked the Plan to pay for the drug testing. 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 supported by the documentation.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly.
Providers must report services with the appropriate CPT code.
We find that CPT code 80307 is not supported in the medical record. Specifically, the documentation did not
include a physician order/lab requisition form stating exactly what tests were to be performed. Based on this
information, we decided that Medicare rules for coverage of the drug testing have not been met. Therefore, we
decided that the Plan does not have to pay for the drug testing coded 80307 provided on August 6, 2019.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for the electronic analysis of a programmable, implanted pump for intrathecal infusion (62370) rendered by the out of network (OON) provider on March 9, 2020.
You asked the Plan to pay for this service. You say that you are requesting a reconsideration of the Plan's denial for payment. The Plan denied your request. The Plan says the service was 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 service at issue in this appeal. The Plan did not pre-approve the service at issue. We found no exception that would require the Plan to pay for this service. Therefore, we decided that the Plan does not have to pay for the electronic analysis of a programmable, implanted pump for intrathecal infusion (62370) rendered by the out of network (OON) provider on March 9, 2020.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the drug testing services provided on August 29, 2019. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the billed services 
cannot be verified. 
 
The Plan must follow Medicare rules. Medicare rules say that the physician must clearly document, in the 
medical record, his or her intent that the test be performed.  
 
We looked at the file and Medicare rules. The records provided do not contain documentation of the ordering 
physician's intent that the tests be performed. 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 
drug testing services provided on August 29, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the Guardant360 testing provided on March 11, 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 were billed incorrectly.
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, this service should be
coded with code 81479. In addition, the appropriate DEX Z code identifier should be provided in the
comment/narrative field adjacent to code 81479. 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 March 11, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the services (S9328) provided from November 25, 2019, to January 20, 2020.
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the services were billed incorrectly.
The Plan must follow Medicare rules. Medicare rules say that a status indicator of "I" under the Physician Fee Schedule indicates that the code in question is not valid for Medicare purposes. We looked at the file and Medicare rules. Code S9328 is assigned a status indicator of "I" under the Physician Fee Schedule, which means that this code is not valid for Medicare purposes. Medicare uses another code for reporting of, and payment for, these services. 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 (S9328) provided from November 25, 2019, to January 20, 2020.