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

 
We decided that the Plan does not have to pre-approve a CardioMEMS device (33289, C2624). 
 
You asked the Plan to pre-approve a CardioMEMS device. You say that the services are necessary. The Plan 
denied your request. The Plan says medical necessity has not been established. Therefore, coverage criteria has 
not been met. 
 
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 a CardioMEMS device. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found in this circumstance therapy change based on data obtained from a CardioMEMs 
device has been demonstrated in only one trial to help reduce hospital readmission compared to standard 
medical therapy. Moreover, concerns have been raised about potential bias in this trial calling into question the 
results. Therefore, the efficacy of the CardioMEMS device is uncertain at this time according to leading 
authorities and not recommended in current guidelines for the treatment of heart failure. Medicare coverage 
criteria are not met since the device should still be considered experimental or investigational. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of a CardioMEMS device have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a CardioMEMS device (33289, C2624).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a pneumatic compression device (E0651). 
 
You asked the Plan to pay for a pneumatic compression device. You say that the enrollee requires the device. 
The Plan denied your request. The Plan says the documentation did not support the documented conservative 
care. 
 
The Plan follows Medicare rules. The rules state that a PCD coded as E0651 is covered for the treatment of 
lymphedema extending onto the chest, trunk and/or abdomen after a four-week trial of conservative therapy 
demonstrating failed response. The trial of conservative therapy must include use of an appropriate 
compression bandage system or compression garment, exercise, and elevation of the limb. The garment may be 
prefabricated or custom-fabricated but must provide adequate graduated compression. No trial of conservative 
care was documented. Therefore, we decided that the Plan does not have to pay for a pneumatic compression 
device (E0651).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a lumbar-sacral orthosis (L0650) provided to the enrollee on 
April 15, 2020. 
 
You asked the Plan to pay for the orthosis. You say that the claim should be paid. The Plan denied your 
request. The Plan says there is no itemized billing/shipping invoice to verify the services 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 proof of delivery to support medical necessity for the supplies provided in this 
case. There is no itemized billing/shipping invoice to verify the services billed. 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 lumbar-sacral orthosis (L0650) provided to the enrollee on April 15, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for subsequent nursing facility care provided on April 1, 2020. 
 
You asked the Plan to pay for the subsequent nursing facility care. The Plan denied your request. The Plan says 
non-emergent, non-urgent services with out-of-network providers require prior authorization. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The requested provider in this case is not a network provider with the Plan. The Plan did not pre-approve the 
services at issue. We found no exception that would require the Plan to pay for these services. Therefore, we 
decided that the Plan does not have to pay for subsequent nursing facility care provided on April 1, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Ensure drink nutritional supplements. 
 
You asked the Plan to pre-approve Ensure drink nutritional supplements. You say that you would like the Plan 
to reconsider their denial. The Plan denied your request. The Plan says Ensure drinks are nutritional 
supplements taken orally and are not covered by Medicare or the Plan. 
 
The Plan must follow Medicare rules. The rules say that Medicare does not pay for nutritional supplementation. 
 
The items you asked the Plan to pre-approve are nutritional supplements. Therefore, we decided that the Plan 
does not have to pre-approve Ensure drink nutritional supplements.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to pay for emergency department services (CPT 99282) provided to the 
enrollee on May 1, 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 instead of billing separately, the physicians should select a level of service representative of the 
combined visits and submit the appropriate code for that level. 
 
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 99282 is "Emergency department visit for the evaluation 
and management of a patient, which requires these 3 key components: An expanded problem focused history; 
An expanded problem focused examination; and Medical decision making of low complexity. Counseling 
and/or coordination of care with other providers 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." 
 
We asked our coding reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pay for the services. Our reviewer says that the 
services at issue in this case were not supported by the medical records. Our coding reviewer found the medical 
records document 2 claims (820201340195867) and (820201340195867) by the same provider on the same 
date of service.  CPT 99282 and 99285 were both billed by the same provider with the same diagnosis code of 
S32.9XXA.  CPT 99285 was paid previously and because the enrollee was seen twice in the same day for the 
same diagnosis, CPT 99282 is not separately billable as a distinct, separate service. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the services have not been met. Therefore, we decided that the Plan does not 
have to pay for emergency department services (CPT 99282) provided to the enrollee on May 1, 2020.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the critical care services provided on September 21, 2019. 
 
You asked the Plan to pay for the critical care services (99291). You say that the Plan should pay this claim. 
The Plan denied your request. The Plan says the documentation submitted did not support a critical care visit of 
30-74 minutes was performed on the billed date of service. 
 
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 99291 is Critical care, evaluation and management of the 
critically ill or critically injured patient; first 30-74 minutes.  
 
We find that CPT code 99291 is not supported in the medical record. Specifically, the code cannot be verified 
because the documentation does not include the time spent providing the service. Based on this information, we 
decided that Medicare rules for coverage of the critical care services have not been met. Therefore, we decided 
that the Plan does not have to pay for the critical care services provided on September 21, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the comprehensive oral evaluation (D0150) provided on June 
16, 2020. 
 
You asked the Plan to pay for the dental service. You say that your appointment on the date of service was 4 
days shy of the 6 month time frame. You say that you did not know that you needed to wait exactly 6 months 
since you were seeing a new dentist. You also say that the new dentist office was not aware of when you had 
your last dentist appointment. The Plan denied your request. The Plan says comprehensive oral evaluations are 
covered once every 3 plan years. The Plan says that the frequency limit for this service has been exceeded. 
 
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, and comprehensive oral evaluations 
are listed as a covered service, the frequency limit has been exceeded. The record shows that you last received 
this service on May 18, 2018, less than 3 years prior. Therefore, we decided that the Plan does not have to pay 
for the comprehensive oral evaluation (D0150) provided on June 16, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a knee orthosis with suspension sleeve (L1851, L2397, 
L2385) provided to the enrollee on April 5, 2020. 
 
You asked the Plan to pay for the orthoses. You say that the claim should be paid. The Plan denied your 
request. The Plan says there is no itemized billing/shipping invoice to verify the services 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 proof of delivery to support medical necessity for the supplies provided in this 
case. There is no itemized billing/shipping invoice to verify the services billed. 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 knee orthosis with suspension sleeve (L1851, L2397, L2385) provided to the 
enrollee on April 5, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for inpatient mental health care provided from April 15, 2020, 
through April 23, 2020, by an out-of-network provider. 
 
You asked the Plan to pay for inpatient mental health care. You say that the claim should be paid. The Plan 
denied your request. The Plan says prior authorization was not obtained by the provider or facility. The Plan 
states the provider should have verified the member's eligibility, health benefits and obtained authorization 
prior to the member's visit before providing services to the member as outlined on the member's ID card. 
 
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 inpatient mental health care provided from April 
15, 2020, through April 23, 2020, by an out-of-network provider.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Venclexta. 
 
You asked the Plan to pre-approve Venclexta. You say that the medication is necessary. The Plan denied your 
request. The Plan says the enrollee has a medical only policy which does not include Part D prescription 
coverage, therefore the criteria for self-administered drug coverage has not been met. 
 
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-
administered drugs. The self-administered drugs requested here are not among the types which are covered by 
Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve Venclexta.  
 
Benefits for Venclexta may be available under Medicare Part D. Contact the Plan that administers Part D 
benefits for further information concerning any benefits and appeal rights.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for psychotherapy, 45 minutes with patient 
(CPT Code 90834) provided from March 3, 2020, through March 9, 2020, by an out-of-network provider. 
 
You asked the Plan to waive the copayment for the services. You say that you are requesting reimbursement of 
services rendered. The Plan denied your request. The Plan says the claims were processed accordingly with 
your 2020 EOC benefits. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance).  
 
Review of the file show that you received psychotherapy provided from March 3, 2020 through March 9, 2020, 
by an out-of-network provider. You are asked to pay 30% coinsurance for the services. Your EOC states, 
"enrollees must pay 30% coinsurance per out-of-network outpatient mental health care visit. The plan will 
reimburse a maximum of $3,000 for out-of-network (POS) services per calendar year. Covered services 
include: Mental health services provided by a state-licensed psychiatrist or doctor, clinical psychologist, 
clinical social worker, clinical nurse specialist, nurse practitioner, physician assistant, or other Medicare-
qualified mental health care professional as allowed under applicable state laws." 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 psychotherapy, 45 minutes with patient (CPT Code 90834) provided from March 3, 
2020, through March 9, 2020, by an out-of-network provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lumbar-sacral orthosis (L0650) provided on March 30, 2020. 
 
You asked the Plan to pay for the lumbar-sacral orthosis. You say that you would like reconsideration because 
the supply is medically necessary. The Plan denied your request. The Plan says the documentation does not 
include an itemized billing/shipping invoice to indicate the specific supplies or proof of delivery for the billed 
date of service. 
 
The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when there are both a 
physician order and proof of delivery.  
 
The record does not contain a valid proof of delivery for the supplies provided in this case. Specifically, the 
record does not include an itemized shipping/billing invoice to verify the billed supplies. Additionally, the 
record did not include a delivery ticket for the billed date of service. The record shows that the Plan made 
several attempts to obtain the necessary documentation without success. Therefore, we decided that the Plan 
does not have to pay for lumbar-sacral orthosis (L0650) provided on March 30, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for electric stimulator supplies (A4595), shoulder elbow wrist 
hand orthosis (L3960) and wrist hand orthosis (L3916) provided on March 20, 2020. 
 
You asked the Plan to pay for the durable medical equipment. You say that you would like reconsideration 
because the supplies are medically necessary. The Plan denied your request. The Plan says no evidence of an 
established relationship between the member and the ordering physician was discovered. 
 
The Plan must follow Medicare rules. Medicare rules say that for eligible telehealth services, 
telecommunications systems substitute for an in-person encounter. Medicare enrollees are eligible for 
telehealth services only if they are presented from an authorized originating site located in either a county 
outside of a Metropolitan Statistical Area (MSA) or a rural Health Professional Shortage Area (HPSA) located 
in a rural census tract. 
  
A review of the file does not show that the telehealth service was provided in an authorized originating site. 
This means that the telehealth visit is not a covered service under the Medicare program and cannot substitute 
for an in-person encounter. Consequently, the items/services ordered following the noncovered visit are 
likewise noncovered. Therefore, we decided that the Plan does not have to pay for electric stimulator supplies 
(A4595), shoulder elbow wrist hand orthosis (L3960) and wrist hand orthosis (L3916) provided on March 20, 
2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the discharge day management services provided on 
November 7, 2019 billed with CPT code 99239. 
 
You asked the Plan to pay for the billed discharge management services. You say that the records clearly show 
that this service was rendered and was medically necessary. The Plan denied your request. The Plan says the 
note does not show that 31 or more minutes were spent providing this service. 
 
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 99239 is Hospital discharge day management; more than 
30 minutes. 
 
We find that CPT code 99239 is not supported in the medical record. Specifically, the amount of time spent 
with the patient during discharge is not documented. Based on this information, we decided that Medicare rules 
for coverage of the billed discharge management services have not been met. Therefore, we decided that the 
Plan does not have to pay for the discharge day management services provided on November 7, 2019 billed 
with CPT code 99239.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayments for a doppler extremity test and vascular 
surgery office visits provided from November 19, 2019, to November 26, 2019. 
 
You asked the Plan to waive the copayments for extremity test and specialist visits. You say that these services 
were unnecessary due to misdiagnosis. The Plan denied your request. The Plan says the copayment amounts 
you are being charged are 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 $100 
copayment for extremity test and $30 copayment for each specialist visit. There was 1 extremity test, resulting 
in a $100 copayment. There were 2 specialist visits, resulting in a $60 copayment. Therefore, your total cost-
sharing obligation is $160. 
 
You have been asked to pay $100 copayment for extremity test and $30 copayment for each specialist visit. 
Extremity test and specialist visits fall within the "Outpatient Diagnostic Tests and Therapeutic Services and 
Supplies" and "Physician/Practitioner Services, Including Doctor's Office Visits" benefit categories. 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 copayments for a doppler extremity test and vascular surgery office visits 
provided from November 19, 2019, to November 26, 2019.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the medical services provided on December 18, 2019, by an 
OON provider. 
 
You asked the Plan to pay for the medical services. You say that verification of benefits and/or authorization of 
care was obtained from the Plan or the Plan's representative. The Plan denied your request. The Plan says the 
provider that referred the member for the services is a non-participating provider and the provider that rendered 
the services is a non-participating 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 medical services provided on December 18, 
2019, by an OON provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for intravenous infusion services (CPT 96361) provided to the 
enrollee on February 29, 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 the fluid used to administer these drugs is incidental hydration and is not separately payable. 
 
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 96361 is "Intravenous infusion, hydration; each 
additional hour (List separately in addition to code for primary procedure)." 
 
We find that CPT code 96361 is not supported in the medical record. Specifically, this code cannot be 
separately payable. 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 intravenous infusion services (CPT 
96361) provided to the enrollee on February 29, 2020.