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

 
We decided that the Plan does not have to pay for assembly and operation of heart lung machine (99190) 
provided April 15, 2020. 
 
You asked the Plan to pay for Assembly and operation of heart lung machine. You say that these charges for 
the perfusionist that setup and operated the heart-lung machine. The perfusionist is required to be in the 
operating room during the length of the procedure. The Plan denied your request. The Plan says Medicare does 
not pay any provider or supplier other than the hospital for services furnished to the beneficiary while an 
inpatient in hospital. 
 
The Plan must follow Medicare rules. The plan must follow Medicare rules. Medicare rules say that CMS does 
not pay any provider or supplier other than the facility or hospital for services furnished to a beneficiary. The 
facility or hospital must furnish all necessary covered services to the beneficiary either directly or under 
arrangements made with outside providers. The enrollee was an inpatient, therefore all services provided to the 
enrollee will be paid under the global facility claim. Payment for this service would have been included under 
the facility claim. Payment to the physician for this service is the responsibility of the facility or hospital. 
Therefore, we decided that the Plan does not have to pay for assembly and operation of heart lung machine 
(99190) provided April 15, 2020.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for open treatment and/or reduction of vertebral fracture and/or 
dislocation (22326) provided October 18, 2019. 
 
You asked the Plan to pay for the open treatment fracture. You say that you need an expert medical examiner to 
review all attached documentation and reprocess this claim for payment. The Plan denied your request. The 
Plan says the requested service code is not substantiated by the clinical documentation in the medical records. 
 
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 22326 is open treatment and/or reduction of vertebral 
fracture(s) and/or dislocation(s), posterior approach, 1 fractured vertebra or dislocated segment. 
 
We find that CPT code 22326 is not supported in the medical record. Specifically, the operative report did not 
include documentation of an open treatment and/or reduction of a vertebral fracture(s) and/or dislocation(s), 
from a posterior approach, for 1 cervical fractured vertebra or dislocated segment. Based on this information, 
we decided that Medicare rules for coverage of the open treatment fracture have not been met. Therefore, we 
decided that the Plan does not have to pay for open treatment and/or reduction of vertebral fracture and/or 
dislocation (22326) provided October 18, 2019.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for behavioral health treatment (H2012) provided March 5, 2019 
to May 27, 2019. 
 
You asked the Plan to pay for the behavioral health treatment. You say that the service should be covered. The 
Plan denied your request. The Plan says the CPT code at issue is not covered by Medicare. The provider must 
submit a corrected claim. 
 
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 H2012 is not supported in the medical record. Specifically, CPT code H2012 is marked 
with an indicator of "I" which means it is invalid for Medicare purposes and is not covered. A correct claim 
must be submitted by the provider. Based on this information, we decided that Medicare rules for coverage of 
the behavioral health treatment have not been met. Therefore, we decided that the Plan does not have to pay for 
behavioral health treatment (H2012) provided March 5, 2019 to May 27, 2019.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services provided on March 5, 2020. 
 
You asked the Plan to pay for the laboratory services. You say that you would like the Plan to reconsider their 
denial of payment. The Plan denied your request. The Plan says the services are not covered. 
 
The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few 
tests listed above, are not covered. 
 
The tests at issue in this appeal, the laboratory services, were requested solely for screening purposes. Medicare 
does not cover these tests solely for screening purposes. Therefore, we decided that the Plan does not have to 
pay for the laboratory services provided on March 5, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the office visit (99202), tumor excision of the face and scalp 
(21013), tumor excision of the shoulder (23075), and the surgical pathology (88304) rendered by the out of 
network (OON) providers on June 3, 2020 and June 9, 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 out of network 
providers, 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 providers in this case are not network providers 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 office visit (99202), tumor excision of the face and scalp (21013), tumor excision 
of the shoulder (23075), and the surgical pathology (88304) rendered by the out of network (OON) providers 
on June 3, 2020 and June 9, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a specialist visit on April 30, 2020. 
 
You asked the Plan to waive the copayment for a specialist visit. You say that you do not believe you should be 
charged because this service was by phone. The Plan denied your request. The Plan says the copayment you are 
being charged is 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 a $45 
copayment for each Specialist office visit for Medicare-covered services.  
 
You have been asked to pay a $45 copayment for a specialist visit. A specialist visit falls within the 
Physician/Practitioner services, including doctor's office visits 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 a specialist visit on April 30, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for additional non-emergency routine transportation trips 
(A0100). 
 
You asked the Plan to pay for the additional trips. You say that you have to take chemotherapy treatments and 
needs the transportation to get to your doctor appointments. The Plan denied your request. The Plan says this 
request exceeds the benefit frequency limitation. 
 
Medicare does not cover transport in a vehicle that is not an ambulance. However, the Plan offers a 
transportation benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this 
case. The Plan covers a maximum of 24 trips per year.  
 
We looked at your request, the records in the case file, and the rules. Based on this information, we decided 
that you have exhausted the Plan maximum benefit for coverage of routine transportation. Therefore, we 
decided that the Plan does not have to pay for additional non-emergency routine transportation trips (A0100).
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 this is medically necessary. The Plan denied 
your request. The Plan says the clinical documentation does not show that you have diabetic foot disease, and 
you do not wear a brace on the right leg. 
 
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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a stationary bicycle. 
 
You asked the Plan to pre-approve the bike. You say that this is medically necessary. The Plan denied your 
request. The Plan says this is not covered by Medicare or offered as a supplemental benefit. 
 
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 stationary bicycle.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the complete upper denture and lower partial denture. 
 
You asked the Plan to pre-approve the complete upper denture and lower partial denture. You say that you 
were informed dentures or partials were covered when you enrolled. The Plan denied your request. The Plan 
says the services are not covered benefits. 
 
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 the 
complete upper denture and lower partial denture.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the requested physician's services to be provided at the 
in-network benefit level. 
 
You asked the Plan to pre-approve the physician's services to be provided at the in-network benefit level. You 
say that the enrollee has been under the care of this cardiologist since May 2019 and has a trusting 
patient/provider relationship with her. You say that it would be a financial hardship and emotional stress for her 
to have to find a new cardiologist if this physician is not considered in-network. The Plan denied your request. 
The Plan says services with a non-contracted provider are only approved at the in-network benefit level when 
the service is not available through the Plan's provider 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 pre-approve care from out-of-network providers only in cases involving 
emergencies, out of area urgent care and care that cannot be provided by network providers. 
 
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. We found no exception that would require the 
Plan to pre-approve these services. Therefore, we decided that the Plan does not have to pre-approve the 
requested physician's services to be provided at the in-network benefit level.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve custom foot orthotics. 
 
You asked the Plan to pre-approve foot orthotics. You say that the enrollee has hammertoe deformities, bunion 
deformity, onychauxis, calluses and peripheral vascular  disease 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 custom foot orthotics.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the custom fabricated abutment (D6057) and implant 
supported crown (D6066) for tooth #3 and #28. 
 
You asked the Plan to pre-approve the custom fabricated abutment (D6057) and implant supported crown 
(D6066) for tooth #3 and #28. You say that you need the implant to eat properly. You say that you are on a low 
income and cannot afford the services. The Plan denied your request. The Plan says the services are not 
covered benefits. 
 
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 the 
custom fabricated abutment (D6057) and implant supported crown (D6066) for tooth #3 and #28.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a continuous glucose monitor. 
 
You asked the Plan to pre-approve a continuous glucose monitor. You say that your doctor recommends a 
CGM. The Plan denied your request. The Plan says your provider did not submit documentation that you are 
checking blood sugars 4 or more times a day. 
 
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. Your log shows you do not regularly check your blood sugar 4 or 
more times a day. Based on this information, we decided that Medicare rules for coverage of a continuous 
glucose monitor have not been met. Therefore, we decided that the Plan does not have to pre-approve a 
continuous glucose monitor.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve orthotic foot inserts. 
 
You asked the Plan to pre-approve foot inserts. You say that the enrollee is a diabetic and biomechanical 
orthotics are usually approved due to being diabetic. The Plan denied your request. The Plan says the denial of 
authorization for these items is correct, because the requested foot inserts are not part of a shoe that is integral 
to a brace. 
 
The Plan must follow Medicare rules. Medicare rules say that foot orthotics with code L3000 are only covered 
if they are on a shoe that is an integral part of a covered brace and if they are medically necessary for the proper 
functioning of the brace.  
 
We looked at the file and Medicare rules. The requested foot inserts are not covered by Medicare because they 
are not being requested as part of a shoe that is an integral part of a brace. A request for therapeutic footwear 
for the enrollees diabetes would have to be submitted with the appropriate description of the footwear 
according to Medicare guidelines. Based on this information, we decided that Medicare rules for coverage of 
foot inserts have not been met. Therefore, we decided that the Plan does not have to pre-approve orthotic foot 
inserts.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a battery backup. 
 
You asked the Plan to pre-approve the backup. You say that this is medically necessary. The Plan denied your 
request. The Plan says this is not a covered benefit. 
 
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 battery backup.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the implant maintenance procedures.  
 
You asked the Plan to pre-approve the implant maintenance procedures. You say that dental implants require a 
specific type of cleaning. You say that you are unable to pay without the assistance from insurance. The Plan 
denied your request. The Plan says the service is not a covered benefit. 
 
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 the 
implant maintenance procedures.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a repeat computed tomography (CT) scan of the chest. 
 
You asked the Plan to pre-approve these services. You say that the enrollee is at high risk for lung cancer. The 
Plan denied your request. The Plan says the services are not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that CT scans are covered only when they are 
medically necessary.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve these services. Our reviewer says that 
the services are not medically necessary. Our physician reviewer found the enrollee has shortness of breath and 
a cough. He quit smoking 30 years ago. A chest x-ray showed an infiltrate and he was treated with antibiotics 
without improvement. Repeat chest x-ray showed chronic scarring. Another repeat CT is not supported as 
follow-up or screening in this clinical situation. The services are therefore not reasonable or medically 
necessary. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of these services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a repeat computed tomography (CT) scan of the chest.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the office physician visit provided on March 16, 2020 by an 
out of network (OON) provider. 
 
You asked the Plan to pay for the office physician visit. You say that do not penalize the doctor for the 
enrollee's PCP's inactions. It is their responsibility to obtain the proper referral from the plan before the doctor 
sees the patients. The Plan denied your request. The Plan says enrollee's must receive their medical services 
from an in-network provider with the exception being urgent or emergent services. The plan says that non-
emergent services with non-contracted providers require prior authorization before services being rendered. 
 
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 office physician visit provided on March 16, 
2020 by an out of network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Freestyle Libre continuous glucose monitor and sensors. 
 
You asked the Plan to pre-approve Freestyle Libre continuous glucose monitor and sensors. 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 device. 
 
The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs and related supplies are 
covered by Medicare when all of the following coverage criteria (1-6) are met: 
1. The beneficiary has diabetes mellitus (Refer to the ICD-10 code list in the LCD-related Policy Article for 
applicable diagnoses); and, 
2. The beneficiary has been using a BGM and performing frequent (four or more times a day) testing; and, 
3. The beneficiary is insulin-treated with multiple (three or more) daily injections of insulin or a Medicare-
covered continuous subcutaneous insulin infusion (CSII) pump; and, 
4. The beneficiary's insulin treatment regimen requires frequent adjustment by the beneficiary on the basis of 
BGM or CGM testing results; and, 
5. Within six (6) months prior to ordering the CGM, the treating practitioner has an in-person visit with the 
beneficiary to evaluate their diabetes control and determined that criteria (1-4) above are met; and, 
6. Every six (6) months following the initial prescription of the CGM, the treating practitioner has an in-
person visit with the beneficiary to assess adherence to their CGM regimen and diabetes treatment plan. 
 
 
 
 
We looked at the file and Medicare rules. Review of the file shows that the enrollee only require 2 insulin 
injections per day, and the enrollee only checks their blood sugar only three times per day. Based on this 
information, we decided that Medicare rules for coverage of Freestyle Libre continuous glucose monitor and 
sensors have not been met. Therefore, we decided that the Plan does not have to pre-approve Freestyle Libre 
continuous glucose monitor and sensors.