Persius/hicric huggingface dataset:
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the Ophthalmological medical examination 
(92014) provided on June 26, 2020. 
 
You asked the Plan to waive the copayment for the examination. You say that you would like reconsideration 
because this was your annual eye exam which should not have a copayment. The Plan denied your request. The 
Plan says you are responsible for a $45 copayment for medical covered exams to treat diseases or conditions of 
the eye. 
 
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 $45 
copayment for each Medicare covered exam to diagnose and treat diseases or conditions of the eye. 
 
You have been asked to pay a $45 copayment for the examination. This eye exam falls within the medical eye 
exam 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 Ophthalmological medical 
examination (92014) provided on June 26, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a household generator. 
 
You asked the Plan to pre-approve a generator. You say that if electricity goes out, there will be no power for 
the enrollee's ventilator. The Plan denied your request. The Plan says the generator is not a covered item. 
 
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 household generator.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pay for home infusion therapy (S9348) provided on March 18, 2020, 
through April 2, 2020. 
 
You asked the Plan to pay for the home infusion therapy. You say that you would like reconsideration based on 
the records submitted. The Plan denied your request. The Plan says CPT code S9348 has a status indicator of I 
which is not valid for Medicare purposes. 
 
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 S9348 is not supported in the record. Specifically, per the Physician Fee Schedule, CPT 
code S9348 has a status indicator of I. This means that CPT code S9348 is not valid for Medicare purposes. 
Based on this information, we decided that Medicare rules for coverage of the home infusion therapy have not 
been met. Therefore, we decided that the Plan does not have to pay for home infusion therapy (S9348) 
provided on March 18, 2020, through April 2, 2020.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for radiology services (CPT 71045) provided to the enrollee on 
April 28, 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 an appropriate modifier indicating that this service was distinct was not appended. 
 
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 CPT code 
71045 has a bundled relationship with codes 36561 and 77001 and cannot be paid as billed. This code cannot 
be paid as a separate line item without the appropriate modifier. Based on the claim submitted, Medicare billing 
criteria have not been met. Therefore, we decided that the Plan does not have to pay for radiology services 
(CPT 71045) provided to the enrollee on April 28, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the new patient assisted living visit and established patient 
assisted living visit (99327, 99336) provided on April 9, 2020, to May 28, 2020 by an out-of-network (OON) 
provider. 
 
You asked the Plan to pay for the new patient assisted living visit and established patient assisted living visit. 
You say that the services provided were medically necessary. The Plan denied your request. The Plan says 
prior authorization was not obtained by the facility or the provider; therefore, payment has been correctly 
denied. 
 
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 new patient assisted living visit and 
established patient assisted living visit (99327, 99336) provided on April 9, 2020, to May 28, 2020 by an out-
of-network (OON) provider.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for enterolysis (44005) provided on March 14, 2020. 
 
You asked the Plan to pay for enterolysis. You say that this was medically necessary. The Plan denied your 
request. The Plan says this procedure is not documented. 
 
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 44005 is enterolysis (freeing of intestinal adhesion) 
(separate procedure). 
 
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 enterolysis. Our reviewer says that the use of 
this code is not supported. Our physician reviewer found this procedure  is not documented in the operative 
report, therefore this service cannot be verified. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of enterolysis have not been met. Therefore, we decided that the Plan does not 
have to pay for enterolysis (44005) provided on March 14, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a power wheelchair and accessories. 
 
You asked the Plan to pre-approve a power wheelchair and accessories. You say that you need a new power 
wheelchair. The Plan denied your request. The Plan says the information submitted does not have physiatry 
evaluation to determine functional level or capacity to operate the power wheelchair. 
 
The Plan follows Medicare rules. Medicare rules say that a PMD will not be covered if the patient does not 
have mobility deficit that impairs their participation in MRADLs, the patient?s condition can be ameliorated by 
a walker, cane or manual wheelchair, or the patient is not capable of safely operating the requested PMD.  
 
There is no record of a specialty evaluation or home evaluation. This means that Medicare rules for coverage of 
 
 
a PMD have not been met. Therefore, we decided that the Plan does not have to pre-approve a power 
wheelchair and accessories.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve power wheelchair accessories (expandable controller, 
harness, electronic connection, armpads, maxx style cane mounted height/width) for the enrollee. 
 
 
 
 
You asked the Plan to pre-approve the accessories. 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 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 accessories. Our reviewer says that 
the requested accessories are not considered medically reasonable and necessary in this case. Our physician 
reviewer found the enrollee's left upper extremity strength should be sufficient to control any power options 
through their own switches. Additionally the K0108 maxx style armrests and K0108 armpads x 2 are not 
medically necessary as they would exceed the enrollee's medical need. The approved wheelchair and accessory 
items have armrests and armpads already included. 
 
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 accessories have not been met. Therefore, we decided that the Plan does not 
have to pre-approve power wheelchair accessories (expandable controller, harness, electronic connection, 
armpads, maxx style cane mounted height/width) for the enrollee.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve foot orthotics. 
 
You asked the Plan to pre-approve foot orthotics. You say that you can't put pressure on your foot. 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 pre-approve foot orthotics.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for Magnetic Resonance Imaging (MRI) of the 
brain (70551) provided June 9, 2020. 
 
You asked the Plan to waive the copayment for the MRI. You say that the copayment should be waived. The 
Plan denied your request. The Plan says the correct copayment was 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 $375 
copayment for Diagnostic Radiology.  
 
You have been asked to pay a $375 copayment for the MRI. The MRI falls within the Diagnostic Radiology 
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 Magnetic Resonance Imaging 
(MRI) of the brain (70551) provided June 9, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services. 
 
You asked the Plan to pre-approve the LTACH services. You say that the LTACH services are medically 
necessary. The Plan denied your request. The Plan says the enrollee does not meet the requirements for 
LTACH. 
 
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically 
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 
 
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 LTACH services. Our reviewer says 
that the requested LTACH care is not considered medically reasonable and necessary in this case. Our 
physician reviewer found transfer to a LTACH is not medically necessary at this time. The enrollee is receiving 
appropriate care at the current acute care facility. The review has determined that the enrollee does not require 
services at the LTACH that are not available at the acute care hospital where he is currently receiving care. 
There are no services available at the LTACH that the enrollee requires that are not available at the health care 
setting being offered by the health plan. The requested LTACH services are not medically necessary, 
reasonable, and appropriate for the diagnosis and condition of the enrollee and able to be furnished safely and 
effectively only on an inpatient basis. 
 
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 LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve long term acute care hospital (LTACH) services.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve long-term acute care hospital (LTACH) services. 
 
You asked the Plan to pre-approve the LTACH services. You say that the services required by the enrollee 
exceeds the clinical capabilities of all lower levels of care. The Plan denied your request. The Plan says the 
enrollee is receiving appropriate care at the current acute care facility. 
 
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically 
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 
 
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 LTACH services. Our physician 
reviewer found that the enrollee was admitted to the acute care hospital with a history of coronary artery 
disease and hypertension. Her hospital course was complicated by bradycardia, pneumonia, epistaxis and 
bloody output from an NG tube. A transfer to an LTACH is not medically necessary at this time. The enrollee 
is receiving appropriate care at the current acute care facility. The enrollee does not require services at the 
LTACH that are not available at the acute care hospital where he/she is currently receiving care. The requested 
LTACH services are not medically necessary, reasonable, and appropriate for the diagnosis and condition of 
the enrollee and able to be furnished safely and effectively only on an inpatient basis. 
 
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 LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve long-term acute care hospital (LTACH) services.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the medical services provided on January 16, 2020 by an out 
of network (OON) provider. 
 
You asked the Plan to pay for the posterior tibial neurostimulation (64566). You say that you would like 
reconsideration because the services rendered were medically necessary. The Plan denied your request. The 
Plan says utilization of network providers is required when possible and 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 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 January 16, 2020 
by an out of network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the medical services provided on September 6, 2019 by an 
out of network (OON) provider. 
 
You asked the Plan to pay for the nursing facility and routine foot care. You say that you would like 
reconsideration because the services rendered were medically necessary. The Plan denied your request. The 
Plan says the services provided were not emergent and not authorized by the Plan. 
 
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 September 6, 
2019 by an out of network (OON) provider.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an MRI scan of tissue elasticity (76391). 
 
You asked the Plan to pre-approve an MRI scan of tissue elasticity. You say that an MRI scan of tissue 
elasticity is medically necessary. The Plan denied your request. The Plan says rules for an MRI scan of tissue 
elasticity have not been met. 
 
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 an MRI scan of tissue elasticity. Our 
reviewer says that the service is not medically necessary. Our physician reviewer found that there is no 
documentation provided that would support this study and no indication in the records provided. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of an MRI scan of tissue elasticity have not been met. Therefore, we decided that 
the Plan does not have to pre-approve an MRI scan of tissue elasticity (76391).
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the physical and occupational therapy provided on January 1, 
2020 to January 23, 2020 by an out of network (OON) provider. 
 
You asked the Plan to pay for physical and occupational therapy. You say that the services were medically 
necessary. The Plan denied your request. The Plan says prior authorization must be obtained for non-emergent 
services rendered for an out-of-network provider. 
 
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 physical and occupational therapy provided on 
January 1, 2020 to January 23, 2020 by an out of network (OON) provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services. 
 
You asked the Plan to pre-approve the LTACH services. The Plan denied your request. The Plan says you are 
receiving appropriate care at the current acute care facility. 
 
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically 
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 
 
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 LTACH services. Our physician 
reviewer found that you were admitted to the acute care hospital for a small bowel obstruction, and underwent 
surgery. A review of the records show that you are receiving appropriate care at the current acute care facility. 
You do not require services at the LTACH that are not available at the acute care hospital where you are 
currently receiving care. The requested LTACH services are not medically necessary, reasonable, and 
appropriate for the diagnosis and condition of the enrollee and able to be furnished safely and effectively only 
on an inpatient basis. 
 
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 LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve long term acute care hospital (LTACH) services.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for arthroscopy, shoulder, surgical; subacromial decompression 
(29826) provided November 11, 2019. 
 
You asked the Plan to pay for arthroscopic subacromial decompression. You say that an assistant is allowed for 
the billed procedure and only 1 unit was billed on this claim. Your physician rendered medically necessary 
services in good faith The Plan denied your request. The Plan says units exceeds Medicare MUE MAI. 
 
The Plan must follow Medicare rules. Medicare rules say that claims submitted where the unit of service 
exceeds the MUE value for the HCPCS/CPT code will be denied. 
 
In this case, the MUE for CPT code 29826 is 1. You billed for 2 units of this code, exceeding the MUE. Based 
on this information, we decided that Medicare rules for coverage of arthroscopic subacromial decompression 
have not been met. Therefore, we decided that the Plan does not have to pay for arthroscopy, shoulder, 
surgical; subacromial decompression (29826) provided November 11, 2019.