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

 
We decided that the Plan does not have to pay for surgical dressing supplies (A6021, A6196, A6212) provided 
on November 27, 2019. 
 
You asked the Plan to pay for surgical dressing supplies. You say that this was billed correctly. The Plan 
denied your request. The Plan says this was billed with an incorrect place of service and there is not a valid 
physician order. 
 
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 physician order for the supplies provided in this case. The order in the file 
has a signature date after the billed date of service. Therefore, we decided that the Plan does not have to pay for 
surgical dressing supplies (A6021, A6196, A6212) provided on November 27, 2019.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the drug tests provided on January 23, 2020 by an OON 
provider. 
 
You asked the Plan to pay for the drug tests. You say that you are a specialized laboratory that performs drug 
monitoring in good faith, at the request of the ordering physician. The Plan denied your request. The Plan says 
the services were rendered by an OON provider, and were not referred by a network provider. The Plan also 
says that the services were not approved in advance. 
 
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 drug tests provided on January 23, 2020 by an 
OON provider.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a referral for a knee arthroplasty with an out-of-network 
provider. 
 
You asked the Plan to pre-approve the referral. You say that this is medically necessary. The Plan denied your 
request. The Plan says there are alternative in-network orthopedic surgeons available. 
 
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 referral for a knee arthroplasty with an out-of-network provider.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Vertiflex device. 
 
You asked the Plan to pre-approve the Vertiflex device. You say that the requested Vertiflex device is 
medically necessary. The Plan denied your request. The Plan says the requested Vertiflex device is not 
medically necessary. 
 
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 Vertiflex device. Our reviewer says 
that the requested Vertiflex device is not medically necessary. Our physician reviewer found the enrollee is 
with spinal stenosis. The requested Vertiflex device is experimental. More research is needed to show safety 
and efficacy. The request is not medically reasonable or 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 Vertiflex device have not been met. Therefore, we decided that the Plan 
does not have to pre-approve the Vertiflex device.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for the romosozumab injection you received 
on April 1, 2020. 
 
You asked the Plan to waive the coinsurance for the romosozumab injection. You say that if you were able to 
administer this drug yourself, it would be less expensive. The Plan denied your request. The Plan says it has 
waived the cost sharing related to the drug administration charges.  However, the plan says that the coinsurance 
you have been charged for the drug itself is correct. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay 20% 
coinsurance for Medicare Part B-covered drugs.  
 
You have been asked to pay 20% coinsurance for the romosozumab injection. Because you are receiving this 
drug from your doctor, the romosozumab injection falls within the Medicare Part B-covered drugs benefit 
category. The Medicare-allowed amount for this drug is $1,898.40, so your 20% coinsurance is $379.68. This 
means that you have been asked to pay the correct amount based on your contract with the Plan. This cost 
sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that 
the Plan does not have to waive the coinsurance for the romosozumab injection you received on April 1, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lower limb prosthetics provided on December 5, 2018. 
 
You asked the Plan to pay for prosthetic items. You say that you are appealing. The Plan denied your request. 
The Plan says the denial of payment for these items is correct, because the documentation submitted does not 
include a valid physician order. 
 
The Plan must follow Medicare rules. Medicare rules say that a detailed written order must be submitted for 
lower limb prostheses. If a supplier bills for lower limb prostheses without first receiving a completed detailed 
written order, the claim will be denied as not reasonable and necessary. The rules also say that a provider must 
furnish to the Plan sufficient information to determine whether payment is due for a claim. 
 
We looked at the file and Medicare rules. You have not submitted a valid detailed written order for the items 
billed. The Plan requested this information, but it was not provided. Without this document, you have not 
furnished sufficient information to the Plan to justify payment of the claim as it has been billed. Based on this 
information, we decided that Medicare rules for coverage of prosthetic items have not been met. Therefore, we 
decided that the Plan does not have to pay for lower limb prosthetics provided on December 5, 2018.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for CT of the abdomen and pelvis (74177) provided on May 11, 
2020. 
 
You asked the Plan to pay for the CT of the abdomen and pelvis. You say that you would like reconsideration 
based on the records submitted. The Plan denied your request. The Plan says two or more diagnosis codes are 
mismatched. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the CT of the abdomen and pelvis have not been met. Specifically, the claim includes mismatched 
diagnosis codes, one for the right lower quadrant of the abdomen and one for an unspecified lower abdomen. 
Therefore, we decided that the Plan does not have to pay for CT of the abdomen and pelvis (74177) provided 
on May 11, 2020.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Vertiflex Superion spacer. 
 
You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied 
your request. The Plan says the services are not medically necessary. 
 
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 these services. Our reviewer says that 
the services are not medically necessary. Our physician reviewer found the enrollee has a greater than seven 
month history of back pain radiating into the bilateral lower extremities. Current evidence based medical 
guideline and peer reviewed literature do not fully support the spinal decompression device procedure over the 
gold standard of lumbar laminectomy. The Vertiflex Superion spacer is considered 
experimental/investigational in nature; therefore, this request does not meet Medicare criteria as medically 
reasonable and necessary for treatment of this enrollee's medical condition. 
 
We looked at this physician's review, the file, and Medicare rules. 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 pre-approve a Vertiflex Superion spacer.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Magnetic Resonance Imaging (MRI) of the cervical 
spine (72141). 
 
You asked the Plan to pre-approve the MRI. You say that the MRI is medically necessary. The Plan denied 
your request. The Plan says this procedure was authorized previously and without the results from the previous 
MRI, another MRI cannot be approved. 
 
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. Our reviewer says that the 
MRI is not medically necessary. Our physician reviewer found an MRI of cervical spine without contrast, was 
approved from 08/04/2020 to 10/03/2020. There is no provided documentation showing the results of this 
study. Guidelines do not support additional imaging without knowing the outcome of the prior approved 
request. 
 
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 have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Magnetic Resonance Imaging (MRI) of the cervical spine (72141).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the deductible for diabetic vision care services provided on 
February 11, 2020. 
 
You asked the Plan to waive the deductible for the diabetic vision care services. You say that diabetic eye 
exams should be covered at 100%. The Plan denied your request. The Plan says you had not yet met your 
annual deductible when you had these services, so the deductible was applied here. 
 
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 there is a $250 deductible that applies to diabetic vision care services. The Plan 
has followed Medicare rules by clearly disclosing in the contract that there is a $250 deductible that applies to 
vision care services. This cost sharing is a contractual obligation that had not been met at the time the diabetic 
vision care services was received on February 11, 2020. Therefore, we decided that the Plan does not have to 
waive the deductible for diabetic vision care services provided on February 11, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the medical services to be provided by an out of 
network (OON) provider. 
 
You asked the Plan to pre-approve the extremity study. You say that you would like reconsideration because 
this service is medically necessary. The Plan denied your request. The Plan says venous doppler extremity 
studies for the follow up of known conditions are not urgently needed services and not covered 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 
the medical services to be provided by an out of network (OON) provider.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the services (CPT 70450) provided on May 23, 2020. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says this is a column II 
code. 
 
The Plan must follow Medicare rules. Medicare rules say that if a provider reports the two codes of an edit pair, 
the column two code is denied, and the column one code is eligible for payment. Procedure code 70450 is part 
of an edit pair with procedure code 70496. Procedure code 70496 is a column one code, and procedure code 
70450 is a column two code. Procedure code 70496 has been billed for this date of service, which means that 
procedure code 70450 is not eligible for payment. Therefore, we decided that the Plan does not have to pay for 
the services (CPT 70450) provided on May 23, 2020.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home visit (99348) provided on August 1, 2019. 
 
You asked the Plan to pay for the home visit. You say that you would like reconsideration because the services 
rendered were medically necessary. The Plan denied your request. The Plan says the submitted billed code does 
not appropriately reflect the services provided by the registered nurse. 
 
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 99348 is home visit for the evaluation and management 
of an established patient, which requires at least 2 of these 3 key components: An expanded problem focused 
interval history; An expanded problem focused examination; Medical decision making of low complexity. 
Counseling and/or coordination of care with other physicians, other qualified health care professionals, or 
agencies are provided consistent with the nature of the problem(s) and the patient's and/or family's needs. 
Usually, the presenting problem(s) are of low to moderate severity. Typically, 25 minutes are spent face-to-face 
with the patient and/or family.  
 
We find that CPT code 99348 is not supported in the record. Specifically, the record does not indicate that the 
physician was present in the home. Based on this information, we decided that Medicare rules for coverage of 
the home visit have not been met. Therefore, we decided that the Plan does not have to pay for the home visit 
(99348) provided on August 1, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for eye refraction services (92015) provided June 3, 2020 to 
June 26, 2020. 
 
You asked the Plan to pay for the refraction services. You say that your doctor required a refractive exam prior 
to cataract surgery. The Plan denied your request. The Plan says refractive services are not covered under the 
plan benefits unless rendered by a routine vision care provider. 
 
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 performed as a routine eye exam and rendered by a participating 
provider. 
 
 
 
We looked at the file and the Plan's rules. Eye refraction services are only covered if performed by a 
participating provider and performed as part of a routine eye exam. Based on this information, we decided that 
the Plan's rules for coverage of the refraction services have not been met. Therefore, we decided that the Plan 
does not have to pay for eye refraction services (92015) provided June 3, 2020 to June 26, 2020.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the genetic testing rendered on May 18, 2020. 
 
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says the claim was billed incorrectly. 
 
The Plan must follow Medicare rules. The rules say that laboratory shall not report multiple individual CPT 
codes describing the component test results.  
 
We looked at the file and Medicare rules. The file shows that the testing at issue has component test results and 
was not billed as one test under code 81479. Therefore, we decided that the Plan does not have to pay for the 
genetic testing rendered on May 18, 2020.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the requested shoulder surgery. 
 
You asked the Plan to pre-approve the requested shoulder surgery. You say that the requested shoulder surgery 
is medically necessary. The Plan denied your request. The Plan says the requested shoulder surgery is not 
medically necessary. 
 
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 requested shoulder surgery. Our 
reviewer says that the requested shoulder surgery is not medically necessary. Our physician reviewer found the 
enrollee is with right shoulder pain. There is not a recent and sufficient trial of physical therapy for shoulder 
pain documented adequately prior to surgery. The shoulder surgery is not medically needed 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 requested shoulder surgery have not been met. Therefore, we decided that 
the Plan does not have to pre-approve the requested shoulder surgery.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the colonoscopy with polypectomy and 
biopsy you had on July 1, 2020. 
 
You asked the Plan to waive the copayment for the colonoscopy. You say that you were under the impression 
that this service would be covered in full. The Plan denied your request. The Plan says you were charged this 
copayment 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 $250 
copayment for outpatient surgery.  
 
You have been asked to pay a $250 copayment for the colonoscopy. Because you had polyps removed and 
biopsied during this colonoscopy, this procedure falls within the outpatient surgery benefit category. This 
means that you have been asked to pay the correct amount based on your contract with the Plan. This cost 
sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that 
the Plan does not have to waive the copayment for the colonoscopy with polypectomy and biopsy you had on 
July 1, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for physician's services for a drug test provided on May 28, 
2020. 
 
You asked the Plan to pay for the physician's services. The Plan denied your request. The Plan says prior 
authorization was not obtained as required under the Plan benefits. 
 
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 physician's services for a drug test provided on May 28, 2020.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve SNF admission. 
 
You asked the Plan to pre-approve the SNF admission. You say that you would like reconsideration because 
the SNF services are medically necessary. The Plan denied your request. The Plan says you are not medically 
stable and need to remain in the hospital. 
 
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 the SNF admission. Our reviewer says 
that daily skilled services are not necessary. Our physician reviewer found you do not meet severity of illness 
or intensity of service criteria for an inpatient basis in a skilled nursing facility setting. 
 
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 SNF admission have not been met. Therefore, we decided that the Plan does 
not have to pre-approve SNF admission.