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

 
We decided that the Plan does not have to pay for a wrist-hand-finger orthosis provided on January 17, 2020. 
 
You asked the Plan to pay for orthosis. You say that you are appealing with supporting records. The Plan 
denied your request. The Plan says the denial of payment for this item is correct, because the documentation 
submitted did not include proof of delivery indicating the specific billed item was delivered to the enrollee.  
 
The Plan must follow Medicare rules. Medicare rules say that the provider must furnish to the Plan sufficient 
information to determine whether payment is due for a claim. The rules also say that the information submitted 
by the provider must corroborate the documentation in the medical records and confirm that coverage criteria 
have been met. 
 
We looked at the file and Medicare rules. The documentation submitted does not include proof of delivery for 
the specific item billed on this claim. The documentation includes a delivery ticket which was not signed by the 
beneficiary to substantiate delivery, and a proof of delivery sheet which does not support delivery of the 
specific item billed on the claim. The Plan requested additional information to support delivery of the item 
billed but it was not provided. Without this information, you have not furnished sufficient information to the 
Plan to justify payment of the claim as billed. Based on this information, we decided that Medicare rules for 
coverage of orthosis have not been met. Therefore, we decided that the Plan does not have to pay for a wrist-
hand-finger orthosis provided on January 17, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit provided on March 18, 2020 by an out of 
network (OON) provider. 
 
You asked the Plan to pay for an office visit. 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 can 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 an office visit provided on March 18, 2020 by an 
out of network (OON) provider.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pay for insulin injections provided from April 7, 2015 to October 28, 
2018 under Medicare Part B. 
 
You asked the Plan to pay for insulin injections under Medicare Part B for the dates in question. You say that 
the Plan should pay for these under Medicare Part B. The Plan denied your request. The Plan says based on the 
review of the medical records received, it was determined your insulin injection did not became effective under 
the Part B benefits until December 28, 2019. Therefore, the reimbursement request for coverage of the insulin 
injection rendered provided on January 23, 2019 was approved. However, the services rendered from April 7, 
2015 through October 28, 2018 remains denied as Part D coverage. Therefore, the Part D copayment applied 
appropriately. 
 
The Plan must follow Medicare rules. Medicare has specific coverage criteria for insulin. Based on the records 
provided, for the dates in question, your insulin was covered under Medicare Part D.  Therefore, we decided 
that the Plan does not have to pay for insulin injections provided from April 7, 2015 to October 28, 2018 under 
Medicare Part B.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the chest x-ray (71045), portable x-ray equipment set up 
(Q0092), and the portable x-ray transport (R0070) rendered by the out of network (OON) provider on  
February 7, 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 chest x-ray (71045), portable x-ray equipment set up (Q0092), and the portable  
x-ray transport (R0070) rendered by the out of network (OON) provider on February 7, 2020.
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to hold you harmless for the office visit you received on May 19, 2020. 
 
You asked the Plan to hold you harmless for the visit. The Plan denied your request. The Plan says that the 
services were billed incorrectly. 
 
Medicare rules say that a contract provider is an agent of the plan. Services and referrals given by a contract 
provider are considered approved by the plan unless notice is provided that the services will not be covered. 
The Plan follows these rules. 
 
You were provided the services by a contract provider. The file does not show that the Plan provided notice 
that the visit would not be covered. You do not have control over how the provider bills the services. Under 
Medicare rules, this means the visit is considered approved by the Plan. Therefore, we decided that the Plan has 
to hold you harmless for the office visit you received on May 19, 2020.  
 
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: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the drug testing services provided on October 22, 2019. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the billed code is 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 G0483 is "Drug test(s), definitive, utilizing (1) drug 
identification methods able to identify individual drugs and distinguish between structural isomers (but not 
necessarily stereoisomers), including, but not limited to gc/ms (any type, single or tandem) and lc/ms (any type, 
single or tandem and excluding immunoassays (e.g., ia, eia, elisa, emit, fpia) and enzymatic methods (e.g., 
alcohol dehydrogenase)), (2) stable isotope or other universally recognized internal standards in all samples 
(e.g., to control for matrix effects, interferences and variations in signal strength), and (3) method or drug-
specific calibration and matrix-matched quality control material (e.g., to control for instrument variations and 
mass spectral drift); qualitative or quantitative, all sources, includes specimen validity testing, per day; 22 or 
more drug class(es), including metabolite(s) if performed." 
 
We find that CPT code G0483 is not supported in the medical record. Specifically, the records do not show that 
22 or more drug classes were tested 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 drug testing services provided on October 22, 2019.
Appeal type: Inpatient Hospital
Decision: Favorable

 
We decided that the Plan has to pay for inpatient readmission provided on November 10, 2019 through 
November 11, 2019. 
 
You asked the Plan to pay for the inpatient readmission. You say that you would like reconsideration because 
the inpatient admission was medically necessary. The Plan denied your request. The Plan says that the member 
was discharged and re-admitted within 24-hours for the same/related diagnosis. 
 
The Plan follows Medicare rules. Medicare rules say that to deny readmission if it was medically unnecessary, 
if it resulted from a premature dishcarge from the same hospital or if it was the result of circumvention of PPS 
by the same hospital. 
 
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 the inpatient readmission. Our reviewer says 
that the member had recently left the hospital and was sent home less than 24- hours earlier however at the time 
of discharge he was hemodynamically stable.  He presented with hypotension , tachycardia and sepsis. Our 
physician reviewer found the two admissions are not contiguous for one DRG payment. The member was not 
discharged and re-admitted within 24-hours for the same/related diagnosis. 
The review has determined that the readmission was medically necessary and was not the result from a 
premature discharge from the same hospital. 
 
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 inpatient readmission have been met. Therefore, we decided that the Plan 
has to pay for inpatient readmission provided on November 10, 2019 through November 11, 2019.  
 
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: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve admission to an inpatient rehabilitation facility (IRF). 
 
You asked the Plan to pre-approve IRF care. You say that this is medically necessary. The Plan denied your 
request. The Plan says your condition must be of a level of complexity that requires an intensive and 
coordinated interdisciplinary approach including physician visits at least three times weekly. 
 
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 records do not indicate that there are significant, or complex medical/nursing 
issues that could not be addressed at a SNF level of care.  Ongoing pain medication and other medication 
management, wound/skin care, and daily therapy can be provided at a SNF. A less intensive, longer duration of 
therapy will allow for measurable gains to be attained within a reasonable, and predicted period. An IRF 
intensity is not warranted. 
 
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).
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. You say that the services are necessary. The Plan denied your 
request. The Plan says based on the documentation provided, coverage criteria has not been met. 
 
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 based on the medical records provided the complexity of your nursing, medical and 
rehabilitation needs do not require an acute hospital inpatient stay with an interdisciplinary approach to 
rehabilitation care. You do require physical therapy and occupational therapy services but you do not require an 
intensive inpatient rehabilitation therapy program. There is concern that you will not be able to fully participate 
in and benefit from the intensive rehabilitation therapy program provided in an inpatient rehabilitation facility. 
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 acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a standard size footplate coded as K0042 and an 
electronic connection (E2310) to allow the chairs power tilt feature to be controlled from the primary drive 
control. 
 
You asked the Plan to pre-approve the footplate and electronic connection. You say that you feel that all 
requested items should be approved. The Plan denied your request. The Plan says the footplate is not separately 
reportable on initial issue of a power wheelchair. In addition, the electronic connector is not reasonable and 
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 for the electronic connection (E2310). Our reviewer 
says that the electronic connection requested is not considered medically reasonable and necessary in this case. 
Our physician reviewer found the E2310 connection would exceed the patient's medical need as the patient has 
the strength and function in the upper extremities to operate the power tilt system by its individual switch and 
does not require this to be operated from the wheelchair controller. 
 
 
In addition, since the Plan has approved coverage for the wheelchair itself (K0856), K0042 cannot be 
separately approved as this is considered included with the initial issue of the chair. 
 
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 footplate and electronic connection have not been met. Therefore, we 
decided that the Plan does not have to pre-approve a standard size footplate coded as K0042 and an electronic 
connection (E2310) to allow the chairs power tilt feature to be controlled from the primary drive control.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the debridement service (11042) rendered by the out of 
network (OON) provider on October 24, 2019. 
 
You asked the Plan to pay for this service. You say that you are requesting a reconsideration of the Plan's 
denial for payment. The Plan denied your request. The Plan says the service was 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 service at issue in this appeal. The Plan did not pre-approve the service at issue. We found 
no exception that would require the Plan to pay for this service. Therefore, we decided that the Plan does not 
have to pay for the debridement service (11042) rendered by the out of network (OON) provider on  
October 24, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the domiciliary or rest home visit for the evaluation and 
management of an established patient (99334) rendered by the out of network (OON) provider on January 16, 
2020. 
 
You asked the Plan to pay for this service. You say that you are requesting a reconsideration of the Plan's 
denial for payment. The Plan denied your request. The Plan says the service was 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 service at issue in this appeal. The Plan did not pre-approve the service at issue. We found 
no exception that would require the Plan to pay for this service. Therefore, we decided that the Plan does not 
have to pay for the domiciliary or rest home visit for the evaluation and management of an established patient 
(99334) rendered by the out of network (OON) provider on January 16, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the orthoses and related supplies billed for services provided 
on March 19, 2020. 
 
You asked the Plan to pay for the orthoses. The Plan denied your request. The Plan says the billed supply codes 
cannot be verified. 
 
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. 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 non-covered visit are 
likewise non-covered. 
 
Furthermore, the record does not contain a valid proof of delivery for the date of service at issue in this case. 
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 the orthoses and related supplies billed for 
services provided on March 19, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for a respiratory assist device (E0470) 
provided March 3, 2020. 
 
You asked the Plan to waive the coinsurance for the respiratory assist device. 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 20% 
coinsurance for Durable Medical Equipment.  
 
You have been asked to pay 20% coinsurance for the respiratory assist device. The respiratory assist device 
falls within the Durable Medical Equipment 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 respiratory assist device (E0470) provided March 3, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a seat lift mechanism. 
 
You asked the Plan to pre-approve the mechanism. You say that this is medically necessary for a bad knee and 
a dislocated hip. The Plan denied your request. The Plan says the enrollee is not completely incapable of 
standing up from a regular chair. 
 
The Plan must follow Medicare rules. The rules say that a seat lift mechanism is covered if all of the conditions 
listed above 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 the mechanism. Our reviewer says that 
the requested mechanism is not medically reasonable or necessary. Our physician reviewer found the 
documentation does not reveal objective imaging evidence that you have severe arthritis of the hip. There is no 
evidence of neuromuscular disease. The documentation does not support that the seat lift is likely to affect 
improvement in your condition, or arrest or retard deterioration in your condition. The records do not indicate 
that you are completely incapable of standing from a chair in the home on a physical exam. The records 
indicate that you can ambulate. 
 
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 mechanism have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a seat lift mechanism.