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

 
We decided that the Plan does not have to pay for electrical stimulator supplies (A4595) and gradient 
compression stockings/sleeves (A6549) provided. 
 
You asked the Plan to pay for the electrical stimulator supplies and gradient compression stockings/sleeves. 
You say that you would like reconsideration because these supplies are medically necessary. The Plan denied 
your request. The Plan says the documentation submitted does not include an itemized billing/shipping invoice 
to verify the supplies billed. 
 
The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when there are both a 
physician order and proof of delivery.  
 
The record does not contain a valid proof of delivery for the supplies provided in this case. Specifically, the 
record does not include an itemized billing/shipping invoice or delivery ticket for the billed date of service. The 
record shows that the Plan made several attempts to obtain the necessary documentation without success. 
Therefore, we decided that the Plan does not have to pay for electrical stimulator supplies (A4595) and gradient 
compression stockings/sleeves (A6549) provided.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the emergency department visit (99285) provided on March 
12, 2020. 
 
You asked the Plan to pay for the emergency department visit (99285). You say that you would like the Plan to 
reconsider their denial of payment. The Plan denied your request. The Plan says the services are not covered. 
 
The Plan must follow Medicare rules. Medicare rules say that physicians in the same group practice who are in 
the same specialty must bill and be paid as though they were a single physician. 
 
We find that CPT code 99285 is not supported in the record. Specifically, the record indicates that CPT code 
99285 has been processed and paid to a different provider in the same group with the same specialty on the 
billed date of service. Based on this information, we decided that Medicare rules for coverage of the emergency 
department visit (99285) have not been met. Therefore, we decided that the Plan does not have to pay for the 
emergency department visit (99285) provided on March 12, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a custom fabricated ankle foot orthosis (L1940, L2330). 
 
 
 
You asked the Plan to pre-approve a custom fabricated ankle foot orthosis. You say that the criteria for 
coverage have been met. The Plan denied your request. The Plan says the records do not show this is necessary. 
 
The Plan follows Medicare rules. Medicare rules say that ankle-foot orthoses are covered when medically 
necessary according to the above guidelines. 
 
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 a custom fabricated ankle foot orthosis. 
Our reviewer says that the requested ankle foot orthosis is not medically necessary. Our physician reviewer 
found it is well documented that this patient is suffering with a tight Achilles tendon, which is causing an 
unsteady gait and pain to bilateral feet. The patient is noted to have a diagnosis of contracture right and left 
ankle with other specified joint disorders as well as primary osteoarthritis of the right and left ankle and foot. 
The patient is also noted to have neuropathy, ankle and foot instability, and clinical peripheral vascular disease. 
It does not appear, after reviewing the enclosed progress notes, that this patient is in need of a customized 
device. There is no documentation of tried and failed physical therapy that would allow for strengthening of the 
patient?s lower extremity, nor is there documentation of a malformation of the foot or ankle that would require 
a customized ankle foot orthotic. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of a custom fabricated ankle foot orthosis have not been met. Therefore, we 
decided that the Plan does not have to pre-approve a custom fabricated ankle foot orthosis (L1940, L2330).
Appeal type: DME/ Orthotics
Decision: Favorable

 
We decided that the Plan has to pre-approve a custom fabricated ankle-foot orthosis (L1940) and accessories 
(L2330, L2820). 
 
You asked the Plan to pre-approve a custom fabricated ankle-foot orthosis and accessories. You say that this is 
medically necessary. The Plan denied your request. The Plan says that the criteria for coverage have not been 
met. 
 
The Plan follows Medicare rules. Medicare rules say that ankle-foot orthoses are covered when medically 
necessary according to the above-listed guidelines. 
 
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 a custom fabricated ankle-foot orthosis 
and accessories. Our reviewer says that the requested customized ankle foot orthosis is medically reasonable 
and necessary for this patient. Our physician reviewer found the medical documentation/visit notes supports the 
fact that the enrollee requires ankle and foot stabilization for medical reasons and does have the potential to 
benefit functionally. The patient is noted to have significant ankle contractures which put him at risk for falling. 
Other risk factors include diabetes, neuropathy, and atherosclerosis. The enrollee also meets the following 
criteria including the fact that their condition necessitating the orthosis is expected to be permanent and long-
standing, greater than six months duration. Furthermore, it is noted that the ankle and foot must be controlled in 
more than one plane according to the progress notes. Finally, it is also well documented that the beneficiary has 
neurologic and circulatory pathology to bilateral lower extremity which would require custom fabrication over 
a non-custom model to prevent tissue injury. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of a custom fabricated ankle-foot orthosis and accessories have been met. 
Therefore, we decided that the Plan has to pre-approve a custom fabricated ankle-foot orthosis (L1940) and 
accessories (L2330, L2820).  
 
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: 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 June 30, 2020. 
 
You asked the Plan to waive the copayment for a diagnostic colonoscopy. You say that this was a screening. 
You say that this should be covered 100%. 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 $350 
copayment for outpatient surgery/outpatient hospital.  
 
You have been asked to pay a $350 copayment for a diagnostic colonoscopy. The colonoscopy that was 
provided was diagnostic in nature; therefore, the correct copayment has been applied. A diagnostic 
colonoscopy falls within the outpatient surgery/outpatient hospital 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 June 30, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an eye examination provided to the enrollee on January 15, 
2020. 
 
You asked the Plan to pay for the services. You say that a referral was not able to be made, because the 
enrollee was out-of-state. The Plan denied your request. The Plan says this was out-of-network, not urgent, or 
emergent. 
 
Medicare says that plans must pay for emergency and urgently needed services. The Plan contract says that 
while outside of the service area, coverage is limited to emergencies, urgently needed care, renal dialysis and 
pre-approved care.   
 
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. Our reviewer says that the 
services at issue in this case were not medically reasonable or necessary. Our physician reviewer found the visit 
and care performed by the non-network optometrist did not meet criteria for treatment of urgent or emergent 
disease. Based on the medical notes, the enrollee had hypertension, but no vision or eye-related complaints. 
There was no emergent complaints, and no past medical condition or special services required that would 
necessitate treatment by the non-network optometrist or ophthalmologist.  It would have been medically safe 
and reasonable to delay care until returning to the service are or disenrolling from the plan. 
 
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 an eye examination provided to the enrollee on January 15, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Botox injection. 
 
You asked the Plan to pre-approve Botox. You say that you would like the plan to reconsider their denial. The 
Plan denied your request. The Plan says the requested services are not medically necessary. 
 
The Plan follows Medicare rules. Medicare rules say that Botox is only covered for certain indications. 
 
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 Botox. Our reviewer says that the 
documentation does not support that the requested Botox is medically reasonable or necessary. Our physician 
reviewer found you have a diagnosis of a refractory tremor. A diagnosis of a refractory tremor is not a 
diagnosis/condition listed within LCD L33274. The medical records provided do not otherwise demonstrate 
that you have a condition that meets the Medicare criteria for coverage of Botox. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Botox have not been met. Therefore, we decided that the Plan does not have to 
pre-approve Botox injection.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pay for self-care/home management training provided on June 30, 
2020. 
 
You asked the Plan to pay for the self-care/home management training. The Plan denied your request. The Plan 
says non-emergent, non-urgent services with out-of-network providers require 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 requested provider in this case is not a network provider with the Plan. 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 self-care/home management training provided on June 30, 2020.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve 8 additional physical therapy visits. 
 
You asked the Plan to pre-approve 8 additional physical therapy visits. You say that the enrollee continues to 
improve endurance and strength. You say that he will worsen without additional therapy. The Plan denied your 
request. The Plan says additional visits are not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for medically necessary outpatient 
therapy. 
 
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 8 additional physical therapy visits. Our 
reviewer says that skilled services are not necessary to restore or maintain function or to prevent deterioration 
of the enrollee's condition. Our physician reviewer found that the enrollee has had extensive therapy for this 
condition and was educated in an independent exercise program. Our reviewer says that the unique skills of a 
professional therapist are not required to safely and effectively provide ongoing treatment. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of 8 additional physical therapy visits have not been met. Therefore, we decided 
that the Plan does not have to pre-approve 8 additional physical therapy visits.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the Vitamin D testing provided on June 22, 2020. 
 
You asked the Plan to pay for the Vitamin D 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 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 Vitamin D 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 
Vitamin D testing provided on June 22, 2020.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services coded 80157, 80177, 80201, 80162, 
80159, and 80173 provided on February 5, 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 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 80157, 80177, 80201, 80162, 80159, and 80173 are not supported in the medical 
record. Specifically, the specimen type collected is incorrect for the billed codes; therefore, the codes cannot be 
verified. The tests are to be performed on a blood specimen collected by venipuncture. The submitted 
toxicology request form indicates the specimen was urine. Based on this information, we decided that Medicare 
rules for coverage of the laboratory services have not been met. Therefore, we decided that the Plan does not 
have to pay for the laboratory services coded 80157, 80177, 80201, 80162, 80159, and 80173 provided on 
February 5, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve urology services to be provided by an out of network 
provider. 
 
You asked the Plan to pre-approve 3 additional out-of-network urology visits. You say that it is medically 
necessary to continue to treat the enrollee. The Plan denied your request. The Plan says while they will approve 
3 visits there are par providers in the enrollee's area able to treat the enrollee's condition. 
 
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 services at issue in this appeal. We found no exception that would require the 
Plan to pre-approve these services. Therefore, we decided that the Plan does not have to pre-approve additional 
urology services to be provided by an out of network provider.
Appeal type: SNF
Decision: Favorable

 
We decided that the Plan has to pre-approve skilled nursing facility (SNF) care. 
 
You asked the Plan to pre-approve SNF care. You say that the services are necessary. The Plan denied your 
request. The Plan says that based on the documentation provided, coverage criteria has not been met. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors 
listed above are met. Custodial care is not covered. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve SNF care. Our reviewer says that the 
services are medically necessary. Our physician reviewer found you do have documented skilled nursing needs: 
antibiotic administration, wound care. You do have documented skilled therapy needs. You need to learn how 
to mobilize and tend to tasks given your weight bearing limitation. Daily skilled services are required to 
establish a maintenance program and/or to prevent deterioration of your condition. Your care needs at this 
point, as a practical matter, cannot be provided at a lower level of care. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of SNF care have been met. The Plan must continue coverage for the SNF skilled 
service until such time as the enrollee no longer needs the service and proper notice has been issued, or the 
100-day Medicare benefit is exhausted. Therefore, we decided that the Plan has to pre-approve skilled nursing 
facility (SNF) care.  
 
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: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for radiologic examination, chest (71045) provided June 26, 
2020. 
 
You asked the Plan to pay for the chest x-ray. You say that the claim denied as a duplicate in error. Please 
review and reprocess claim for reimbursement according to contract. The Plan denied your request. The Plan 
says the claim was submitted with a column II procedure to the column I procedure. The chest x-ray is integral 
to the procedure and shall not be reported separately. 
 
 
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, we have confirmed that code the 
chest x-ray has a bundled relationship with code 36556 and cannot be paid as billed. This code cannot be paid 
as a separate line item. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, 
we decided that the Plan does not have to pay for radiologic examination, chest (71045) provided June 26, 
2020.
Appeal type: Surgery
Decision: Favorable

 
We decided that the Plan has to pre-approve right lower extremity endovenous laser treatment and stab 
phlebectomy 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 that this is not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that services are covered if 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 services. Our reviewer says that the 
requested services are considered medically reasonable and necessary in this case. Our physician reviewer 
found the documentation meets all coverage criteria and is supportive of the medical necessity of the treatment 
in question. There is satisfactory documentation of symptom severity, failure of conservative treatments, and 
appropriate anatomy for the treatment selected, including vein size. The health plan has already approved the 
left. The right in fact is more involved, more symptomatic, and the veins are larger. The requested treatments 
appear to be focused on the related symptoms. 
 
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 been met. Therefore, we decided that the Plan has to pre-
approve right lower extremity endovenous laser treatment and stab phlebectomy for the enrollee.  
 
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again 
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake 
and/or send us the new information. This does not happen often. If we decide to open the case again, we will 
send you a letter.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a power wheelchair for the enrollee from an out-of-
network provider. 
 
You asked the Plan to pre-approve the wheelchair. You say that this is medically necessary. The Plan denied 
your request. The Plan says the requested provider is 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 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 
a power wheelchair for the enrollee from an out-of-network provider.