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

 
We decided that the Plan does not have to pre-approve a battery backup for a CPAP machine. 
 
You asked the Plan to pre-approve the backup. You say that you have problems with power outages. The Plan 
denied your request. The Plan says this is not a covered benefit. 
 
The Plan must follow Medicare rules. The rules say Medicare covers DME only when it is reasonable and 
necessary. If DME serves the same purpose as equipment already available to an enrollee, it is not considered 
reasonable and necessary. 
 
A backup battery cannot be covered. Therefore, we decided that the Plan does not have to pre-approve a battery 
backup for a CPAP machine.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay forthe percutaneous transcatheter placement of intracoronary stent(s) services coded 92928 provided on August 24, 2019.You asked the Plan to pay forthe percutaneous transcatheter placement of intracoronary stent(s) 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.ThePlan 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 92928 is percutaneous transcatheter placement of intracoronary stent(s), with coronary angioplasty when performed; single major coronary artery or branch.We find that CPT code 92928 is not supported in the medical record. Specifically, this service was reported without a required anatomical modifier. Based on this information, we decided that Medicare rules for coverage of the percutaneous transcatheter placement of intracoronary stent(s) services have not been met.Therefore, we decided that the Plan does not have to pay forthe percutaneous transcatheter placement of intracoronary stent(s) services coded 92928 provided on August 24, 2019.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services provided to the enrollee on March 18, 2020 and 
billed under codes 80157,80177,80201, 80162, 80159, and 80173. 
 
You asked the Plan to pay for lab services provided to the enrollee. You say that this claim should be paid. The 
Plan denied your request. The Plan says while a portion of the claim was paid, the documentation submitted did 
not support that the denied codes were performed with blood sampling.  Blood specimen collection is by 
venipuncture; however, the lab requisition states a urine specimen was collected; therefore, the billed service 
cannot be verified.  
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate codes. In this case, the claim submitted cannot be paid due 
to an issue with the type of specimen reported. Medicare billing criteria were not met. Therefore, we decided 
that the Plan does not have to pay for lab services provided to the enrollee on March 18, 2020 and billed under 
codes 80157,80177,80201, 80162, 80159, and 80173.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a blood pressure monitor with cuff and blood oxygen finger 
meter provided on June 23, 2020 by an out of network (OON) provider. 
 
You asked the Plan to pay for a blood pressure monitor with cuff and blood oxygen finger meter. You say that 
you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the services 
received are not a covered benefit when provided by an OON 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 a blood pressure monitor with cuff and blood 
oxygen finger meter provided on June 23, 2020 by an out of network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the $395 copayment charged for outpatient hospital services 
provided. 
 
You asked the Plan to waive this copayment. You say that you do not believe this copayment is correct. The 
Plan denied your request. The Plan says this copayment was charged per the Plan contract agreement for this 
type of service. 
 
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 $395 
copayment for outpatient hospital services. 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 $395 copayment charged for outpatient 
hospital services provided.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services provided to the enrollee on November 5, 2019 
and billed under codes 80157,80177,80201,80162,80159 and 80173. 
 
You asked the Plan to pay for these services. You say that this claim should be paid. The Plan denied your 
request. The Plan says while codes G0483 and 80307 were paid, the remaining codes were denied because the 
specimen type reported is incorrect for the billed codes. The Plan states that the denied codes are performed on 
a blood specimen collected by venipuncture. The Plan states the submitted toxicology request form indicates 
the specimen was urine. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate codes. In this case, the claim submitted cannot be paid as 
billed due to an issue with the reported specimen collected.  Medicare rules for coverage of this claim have not 
been met. Therefore, we decided that the Plan does not have to pay for lab services provided to the enrollee on 
November 5, 2019 and billed under codes 80157,80177,80201,80162,80159 and 80173.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for outpatient surgical services provided. 
 
You asked the Plan to waive the coinsurance for the outpatient surgical services. You say that the coinsurance 
should be waived. The Plan denied your request. The Plan says the correct cost-sharing 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 20% 
coinsurance for Outpatient Surgery and Other Medical Services Provided at Hospital Outpatient Facilities and 
Ambulatory Surgical Centers.  
 
You have been asked to pay a 20% coinsurance for the outpatient surgical services. 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 outpatient surgical services provided.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the radiological services provided on June 11, 2020. 
 
You asked the Plan to pay for the radiological services. You say that you would like the Plan to reconsider their 
denial of payment. The Plan denied your request. The Plan says the enrollee enrolled in hospice from April 4, 
2020 through June 3, 2020. The Plan says that, per Medicare guidelines, the provider should bill Original 
Medicare for the services provided on June 11, 2020. 
 
Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice 
services. Original Medicare is responsible for payment for services until the first day of the month after the 
hospice election has been revoked or terminated. 
 
The enrollee ended Medicare Hospice benefits on June 3, 2020. The services in question were provided before 
the end of that month. Therefore, we decided that the Plan does not have to pay for the radiological services 
provided on June 11, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve admission to an inpatient rehabilitation facility (IRF) for 
the enrollee. 
 
You asked the Plan to pre-approve IRF care. You say that this is medically necessary. The Plan denied your 
request. The Plan says care can be received at a lower level of care. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described above. 
 
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 IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found the complexity of the enrollee's nursing, medical and rehabilitation needs do not 
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The enrollee 
does not require an intensive program. Care at the skilled nursing facility level appears to be more appropriate 
in this case. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve admission to an inpatient rehabilitation facility (IRF) for the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for sedation services (99152) provided. 
 
You asked the Plan to pay for sedation services. You say that this is supported in the records. The Plan denied 
your request. The Plan says this 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 99152 is moderate sedation services provided by the 
same physician or other qualified health care professional performing the diagnostic or therapeutic service that 
the sedation supports, requiring the presence of an independent trained observer to assist in the monitoring of 
the patient's level of consciousness and physiological status; initial 15 minutes of intraservice time, patient age 
5 years or older. 
 
We find that CPT code 99152 is not supported in the medical record. Specifically, the presence of an 
independent trained observer is not documented. Based on this information, we decided that Medicare rules for 
coverage of sedation services have not been met. Therefore, we decided that the Plan does not have to pay for 
sedation services (99152) provided.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve suction assisted lipectomy of the lower extremity 
(15879). 
 
You asked the Plan to pre-approve suction assisted lipectomy of the lower extremity. You say that you would 
like the Plan to reconsider their denial. The Plan denied your request. The Plan says the enrollee does not meet 
criteria for the requested suction assisted lipectomy of the lower extremity. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We looked at the file and Medicare rules. Medicare only covers suction assisted lipectomy when the procedure 
is utilized to remove a lipoma if documentation shows medical necessity. The file shows that the request is not 
to remove a lipoma. Based on this information, we decided that Medicare rules for coverage of suction assisted 
lipectomy of the lower extremity have not been met. Therefore, we decided that the Plan does not have to pre-
approve suction assisted lipectomy of the lower extremity (15879).
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 enrollee needs long-term acute care 
hospital services. The Plan denied your request. The Plan says the enrollee can be treated at a lower level of 
care. 
 
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 long term acute care hospitals (LTACHs) are certified as acute care hospitals, and in 
general, LTACHs do not provide clinical services that are materially different than those of short term acute 
care hospitals. The enrollee is receiving acute hospital care, and acute care services have not been denied.  
The documentation does not support that the enrollee in this case requires services at the LTACH that are not 
available at the acute care hospital where she is currently receiving care. There are no required medical services 
identified that are available at the LTACH, that are not available at the current 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 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 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: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for radiology services (CPT 70450) provided to the enrollee. 
 
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 is needed to represent the services as separate and distinct. 
 
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 
70450 has a bundled relationship with CPT code 70496 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 70450) provided to the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive or reduce the cost share charged for outpatient wound care 
provided from April 30, 2020, to May 28, 2020. 
 
You asked the Plan to waive or reduce this cost share. You say that you do not believe this cost share is correct 
because no one told you there would be a copayment. The Plan denied your request. The Plan says this cost 
share was charged based on the services provided and the Plan contract agreement. 
 
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 up to 
$250 copayment for each outpatient surgical or outpatient hospital service.  
 
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 or reduce the cost share charged for outpatient wound care provided from April 30, 
2020, to May 28, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay fora knee orthosis billed to the enrollee for April 3, 2020.You asked the Plan to pay forthis claim. You say that this claim should be paid by the Plan.The Plan denied your request. The Plan says the medical records do not support a valid order for the orthosis 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 physician order. 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 fora knee orthosis billed to the enrollee for April 3, 2020.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services provided to the enrollee on May 6, 2020 and 
billed under codes 80157, 80159, 80162, 80173, 80177, and 80201. 
 
You asked the Plan to pay for lab services provided to the enrollee. You say that this claim should be paid. The 
Plan denied your request. The Plan says while code G0483 was approved, the remaining codes were denied 
because the documentation submitted did not support that the testing was performed with blood sampling. The 
Plan states that blood specimen collection is by venipuncture, however, the lab requisition states a urine 
specimen was collected; therefore, the billed service cannot be verified.  
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate codes. In this case, the claim submitted cannot be paid due 
to an issue with the reported specimen collected. Medicare billing criteria were not met. Therefore, we decided 
that the Plan does not have to pay for lab services provided to the enrollee on May 6, 2020 and billed under 
codes 80157, 80159, 80162, 80173, 80177, and 80201.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the medical services provided to you on August 14, 2020. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the services were 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 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 medical services provided to you on August 14, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waivethe $10 copayments charged for office visit services provided on June 10, 2020 and June 24, 2020.You asked the Plan to waivethese copayments. You say that you do not believe these copayments should apply because they were for Covid 19.The Plan denied your request. The Plan says these copayments were charged based on the services provided and the Plan contract agreement.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 $10 copayment for office visit services.Testing for Covid 19 was covered by the Plan as they paid their share of the cost of these services. Copayments for Covid 19 testing are not waived as a service was provided. 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 waivethe $10 copayments charged for office visit services provided on June 10, 2020 and June 24, 2020.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for drug testing provided to the enrollee on June 12, 2020, and 
billed under code G0482. 
 
You asked the Plan to pay for this service. . You say that this claim should be paid. The Plan denied your 
request. The Plan says The medical records do not contain documentation to support the coding criteria for 
code billed on date of service. Documentation does not support 15-21 drug classes. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate codes. In this case, the medical records provided do not 
support the codes billed on the claim. Medicare billing criteria were not met. Therefore, we decided that the 
Plan does not have to pay for drug testing provided to the enrollee on June 12, 2020, and billed under code 
G0482.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve prefabricated post and core in addition to a crown, 
indirectly fabricated (D2952). 
 
You asked the Plan to pre-approve the dental service. You say that tooth # 12 has a significant amount of tooth 
structure missing. You also say that a prefabricated post and core in addition to a crown is not adequate enough 
to support a crown for tooth # 12. The Plan denied your request. The Plan says prefabricated post and core in 
addition to a crown, indirectly fabricated, is not listed as a covered service. The Plan also says that any service 
that is not listed is not covered. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plan?s coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve 
prefabricated post and core in addition to a crown, indirectly fabricated (D2952).