Persius/hicric huggingface dataset:
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided on May 5, 2020, by an out-of-network provider.

You asked the Plan to pay for the medical services. You say that you are appealing for reconsideration of the denied charges. The Plan denied your request. The Plan says the services were not authorized by the Plan and the services were not medically necessary or emergent.

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 May 5, 2020, by an out-of-network provider.
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to pay for the services (CPT 93010 x2) provided on April 10, 2020.

You asked the Plan to pay for the services. The Plan denied your request. The Plan says the services are not supported.

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 find that CPT code 93010 is not supported in the medical record. Specifically, the documentation submitted does not support two ECG's provided on the date of service in question. 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 (CPT 93010 x2) provided on April 10, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the orthotic devices as defined by codes L4396, L3807, L1930.
You asked the Plan to pay for the orthoses. You say that the devices are necessary. 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. The rules state that DMEPOS is covered only when the patient's medical record contains sufficient documentation of the patient's medical condition to substantiate the necessity for the type and quantity of items ordered and for the frequency of use. The record shows that documentation submitted did not indicate the provider discussed the need for the billed supply code, so the billed supply codes cannot be verified. Therefore, we decided that the Plan does not have to pay for the orthotic devices as defined by codes L4396, L3807, L1930.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an observation stay provided from April 
18, 2020 to April 19, 2020. 
 
You asked the Plan to waive the copayment for an observation stay. You say that you do not understand why 
observation services were necessary when they could have been provided in the emergency room. 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 $500 
copayment for outpatient hospital observation.  
 
The medical records show that you received observation services from April 18, 2020 to April 19, 2020. 
Therefore, you are responsible to pay the $500 copayment.  
 
You have been asked to pay a $500 copayment for an observation stay. An observation stay falls within the 
outpatient hospital observation 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 observation stay provided from April 18, 2020 to April 19, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to preapprove a pneumatic compression device (E0673, E0650, E0666, 
97760). 
 
You asked the Plan to preapprove a pneumatic compression device. You say that the pneumatic compression 
devices are required for clot prevention after surgery. The Plan denied your request. The Plan says the enrollee 
does not have any indications that meet Medicare coverage criteria for the devices or services. 
 
The Plan follows Medicare rules. The rules state that a PCD that provides intermittent limb compression for the 
purpose of prevention of venous thromboembolism is a preventive service. Using a PCD defined by E0650 is 
only covered for the treatment of lymphedema or chronic venous insufficiency with ulcers.  
 
We looked at the file and Medicare rules. Based on this information we decided that Medicare rules for 
coverage of the PCD have not been met. Specifically, these items are not a covered benefit of Medicare or the 
Plan. These items are used for a preventative services and is excluded from Medicare coverage. Therefore, we 
decided that the Plan does not have to preapprove a pneumatic compression device (E0673, E0650, E0666, 
97760).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a chest wall oscillation system (E0483) provided on April 4, 
2020. 
 
You asked the Plan to pay for a chest wall oscillation system. You say that the required documentation has 
been submitted. The Plan denied your request. The Plan says the file does not contain a valid physician's 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 and proof of delivery for the supplies provided in this case. 
The physician order does not indicate the length of need for the item at issue and there is no proof of delivering 
included in the file. 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 a chest wall 
oscillation system (E0483) provided on April 4, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for physician services provided on April 30, 2020 by an out of 
network (OON) provider. 
 
You asked the Plan to pay for physician services. You say that you would like this claim reprocessed and 
approved for payment. The Plan denied your request. The Plan says prior authorization was not obtained. The 
Plan says that these services could be provided in-network. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The requested provider in this case is not a network provider with the Plan. The Plan has network providers 
available who can provide the items/services at issue in this appeal. The Plan did not pre-approve the 
item/service at issue. We found no exception that would require the Plan to pay for these items/services. 
Therefore, we decided that the Plan does not have to pay for physician services provided on April 30, 2020 by 
an out of network (OON) provider.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve home health physical therapy visits. 
 
You asked the Plan to pre-approve the visits. You say that you want to be strong enough to feel comfortable 
getting in and out of the shower. The Plan denied your request. The Plan says you are no longer considered 
homebound. 
 
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 visits. Our reviewer says that the 
requested visits are not medically reasonable or necessary. Our physician reviewer found there are no 
documented skilled nursing needs. You are mobilizing at a level that does not appear to require ongoing skilled 
therapy. You are noted to have family assistance in the home. As such, ongoing home health services are not 
shown to be medically necessary or reasonable. 
 
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 visits have not been met. Therefore, we decided that the Plan does not have 
to pre-approve home health physical therapy visits.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve CT scan of the pelvis for the enrollee. 
 
You asked the Plan to pre-approve the scan. You say that this is medically necessary. The Plan denied your 
request. The Plan says this is not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that CT scans 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 scan. Our reviewer says that the 
requested scan is not medically reasonable or necessary. Our physician reviewer found the details of the 
possibility of acute post thromboembolic disease are not at all explained. No results of a duplex venous scan of 
the right leg are presented.  Likewise, there is no pelvic ultrasound result in the submitted records. The enrollee 
is not on anticoagulants so a workup for right lower extremity DVT is not in the records. Absent any of these 
details the medical necessity of a pelvic CT has not yet been established. A CT of the pelvis without contrast 
has been requested. Presumably an unenhanced scan has been requested due to chronic renal disease. In any 
case, the medical necessity for the scan has not yet been established. 
 
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 scan have not been met. Therefore, we decided that the Plan does not have 
to pre-approve CT scan of the pelvis for the enrollee.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for comprehensive genomic profile (CGP) testing provided on 
September 3, 2019. 
 
You asked the Plan to pay for genetic testing. You say that the enrollee's treating physician ordered this testing 
to determine if there was a more effective therapy to treat the enrollee's condition. The Plan denied your 
request. The Plan says the denial of payment for this testing is correct, because this testing was not billed with 
the appropriate coding. 
 
The Plan must follow Medicare rules. Medicare rules say that CGP testing must be billed with CPT code 81479 
for date of service September 3, 2019.  
 
We looked at the file and Medicare rules. This testing was not billed with the appropriate coding. Based on this 
information, we decided that Medicare rules for coverage of genetic testing have not been met. Therefore, we 
decided that the Plan does not have to pay for comprehensive genomic profile (CGP) testing provided on 
September 3, 2019.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) services. 
 
You asked the Plan to pre-approve the SNF services. You say that the enrollee has a brand new PEG tube that 
has to be continuously monitored for signs and symptoms of infection, functionality for feeding goal rate, and 
continue to check for proper placement.  You say that the enrollee tested positive for occult blood in the stool 
and that repeated labs need to be sent for an updated treatment plan. The Plan denied your request. The Plan 
says the enrollee does not require ongoing skilled nursing care and that proper administration of the tube 
feedings can be performed by non-licensed caregivers in the home setting or in custodial care. The Plan says 
that the criteria for coverage of SNF care have 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 the SNF services. Our reviewer says 
that daily skilled services are not necessary. Our physician reviewer found the enrollee received enteral 
nutrition and medications. The enrollee had stable vital signs and used oxygen via a nasal cannula. There is no 
documentation that the enrollee required or received skilled therapy. There are no identifiable skilled therapy 
service needs. While there are identifiable skilled nursing service needs, they are not required on a daily basis. 
The enrollee does not meet the 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 services have not been met. Therefore, we decided that the Plan does 
not have to pre-approve skilled nursing facility (SNF) services.
Appeal type: Inpatient Hospital
Decision: Favorable

 
We decided that the Plan has to pre-approve acute inpatient hospital care. 
 
You asked the Plan to pre-approve acute inpatient hospital care. You say that the inpatient level of care is 
medically necessary. The Plan denied your request. The Plan says that the inpatient level of care is not 
medically necessary and that the enrollee can receive the care needed at the observational level. 
 
The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor 
expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases, 
consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or 
more. 
 
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 acute inpatient hospital care. Our 
reviewer says that the documentation supports that the criteria for inpatient care are met in this case. Our 
physician reviewer found the enrollee was volume depleted following dialysis and vomited. His volume was 
corrected in the emergency department on arrival on September 28, 2020. The enrollee was clinically stable 
with no signs of aspiration pneumonia. He was afebrile and his respiratory status showed his oxygen saturation 
was 95%. He was discharged home on October 2, 2020, when considered medically stable. The records show 
that at the time of the request for an inpatient admission the admitting physician reasonably expected that the 
enrollee's necessary hospital care (including earlier emergency room and/or observation care) would span two 
midnights. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of acute inpatient hospital care have been met. Therefore, we decided that the Plan 
has to pre-approve acute inpatient hospital 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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the chiropractic manipulative treatment (98941) rendered by 
the out of network (OON) provider from March 4, 2020 to April 20, 2020. 
 
You asked the Plan to pay for these services. You say that you are requesting a reconsideration of the Plan's 
denial for payment. The Plan denied your request. The Plan says the services were 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 services at issue in this appeal. 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 the chiropractic manipulative treatment (98941) rendered by the out of network (OON) 
provider from March 4, 2020 to April 20, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Freestyle Libre continuous glucose monitor (CGM). 
 
You asked the Plan to pre-approve these services. You say that you are afraid of needles and the CGM would 
be better for you. The Plan denied your request. The Plan says the services are not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that a therapeutic CGM is covered 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 pre-approve these services. Our reviewer says that 
the services are not medically necessary. Our physician reviewer found the submitted records show that you 
have Type II diabetes. You do not use insulin to treat diabetes or check your blood glucose levels four times a 
day or more. The request does not meet the criteria for coverage and the CGM is therefore not reasonable or 
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 these services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a Freestyle Libre continuous glucose monitor (CGM).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the rest home visit (99336) provided on April 20, 2020 by an 
out of network (OON) provider. 
 
You asked the Plan to pay for an OON rest home visit. You say that this was a medically necessary service 
provided in good faith. The Plan denied your request. The Plan says this was not authorized. 
 
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 rest home visit (99336) provided on April 20, 
2020 by an out of network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for foot orthotics provided on June 3, 2020. 
 
You asked the Plan to pay for foot orthotics. You say that you need this to walk without pain and for daily 
mobility. The Plan denied your request. The Plan says this item is not a covered benefit. 
 
Medicare rules state that supportive devices for the feet (such as orthotics) are only covered for patients with 
diabetic foot disease or for patients who wear a leg brace. The Plan follows these same rules.   
 
Records show that you do not suffer from diabetic foot disease and you do not wear a leg brace. Although 
orthotics may be appropriate for you, neither Medicare nor the Plan provides coverage of orthotics for your 
condition. Therefore, we decided that the Plan does not have to pay for foot orthotics provided on June 3, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the services you received from November 4, 2019, to 
November 24, 2019. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says this provider is not 
eligible to participate in Medicare. 
 
The Plan must follow Medicare rules. Medicare rules say that no provider or supplier shall receive payment for 
services furnished to a Medicare beneficiary unless the provider or supplier is enrolled in the Medicare 
program.  
 
We looked at the file and Medicare rules. The requested provider is not enrolled in the Medicare program. 
Payment cannot be made to a provider who is not enrolled in the Medicare program. 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 you received from November 4, 2019, to November 24, 2019.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for a Medicare Part B drug provided on April 
6, 2020. 
 
You asked the Plan to waive the coinsurance for a Medicare Part B drug. You say that you have never been 
charged in the past and disagree with the charges. 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 20% 
coinsurance for Medicare Part B prescription drugs.  
 
You have been asked to pay $324.66, which is less than the 20% coinsurance for a Medicare Part B drug. A 
Medicare Part B drug falls within the Medicare Part B prescription drugs 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 coinsurance for a Medicare Part B drug provided on April 6, 2020.