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

 
We decided that the Plan does not have to pay for the medical services provided to the enrollee by an out-of-
network provider on July 27, 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 the enrollee by an out-of-network provider 
on July 27, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Freestyle Libre 14 Day Reader. 
 
You asked the Plan to pre-approve Freestyle Libre 14 Day Reader. You say that the items are necessary. The 
Plan denied your request. The Plan says the Medicare criteria have not been met. 
 
The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are considered medically 
reasonable and necessary for enrollees with diabetes who perform blood glucose testing at least four times per 
day, use insulin with at least three daily injections, and require frequent self-adjustment of insulin dosage based 
on the blood glucose testing results. 
 
We looked at the file and Medicare rules. Based on the medical records sent in, the member has Type 2 
Diabetes and are currently on Metformin, Rybelsus, and Invokana. The member does not use insulin as it has 
caused them to have low blood sugar (hypoglycemia) and they only test their blood sugar three times a day. 
Based on this information, we decided that Medicare rules for coverage of Freestyle Libre 14 Day Reader Each 
have not been met. Therefore, we decided that the Plan does not have to pre-approve Freestyle Libre 14 Day 
Reader.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an MRI and does not have to waive the 
coinsurance for a Medicare Part B drug provided on March 27, 2019. 
 
You asked the Plan to waive the copayment for an MRI and to waive the coinsurance for a Medicare Part B 
drug. You say that you feel that the charges are outrageous. The Plan denied your request. The Plan says the 
claims were processed correctly and you are being charged the correct amount. 
 
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 $225 
copayment for diagnostic radiology services provided at a freestanding facility. Your contract with the Plan 
also clearly says that you must pay 20% coinsurance for Medicare Part B prescription drugs. 
 
You received an MRI on March 27, 2019. Therefore, you are responsible to pay the $225 copayment.  
 
You received a Medicare Part B drug on March 27, 2019. The allowed amount is $147.49 and 20% of that is 
$29.50.  
 
The total amount you owe is: $254.50.  
 
 
 
You have been asked to pay the total amount of $254.50 for an MRI and a Medicare Part B drug. An MRI falls 
within the outpatient diagnostic tests and therapeutic services and supplies benefit category. A Medicare Part B 
drug falls within the Medicare Part B prescription drugs 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 an MRI and does not have to waive the coinsurance for a Medicare Part B drug provided on 
March 27, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home infusion therapy (S9502) and disposable drug 
delivery system (A4305) provided from April 16, 2020 to April 22, 2020. 
 
You asked the Plan to pay for the home infusion therapy and disposable drug delivery system. 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 must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
We looked at the file and Medicare rules. In this case, CPT code S9502 has a status code of "I" under the 
Medicare Physicians Fee Schedule Database (MPFSDB) and is not valid for Medicare purposes. Medicare uses 
another code for reporting of, and payment for, this service. Furthermore, Medicare does not cover disposable 
drug delivery systems (A4305) as they do not meet the Medicare definition of durable medical equipment. 
Therefore, we decided that the Plan does not have to pay for the home infusion therapy (S9502) and disposable 
drug delivery system (A4305) provided from April 16, 2020 to April 22, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the bupivicaine hydrochloride injection coded S0020 
provided on June 11, 2020. 
 
You asked the Plan to pay for the bupivicaine hydrochloride injection. 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 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 S0020 is injection, bupivicaine hydrochloride, 30 ml. 
 
We find that CPT code S0020 is not supported in the medical record. Specifically, this code has a status code 
of "I". A status code of I means that this code is not valid for Medicare purposes. Medicare uses another code 
for reporting of, and payment for these services. Based on this information, we decided that Medicare rules for 
coverage of the bupivicaine hydrochloride injection have not been met. Therefore, we decided that the Plan 
does not have to pay for the bupivicaine hydrochloride injection coded S0020 provided on June 11, 2020.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for computed tomography, thoracic spine 
(72129) and computed tomography, lumbar spine (72132) provided April 17, 2020. 
 
You asked the Plan to waive the copayment for the CT scan. You say that you do not dispute that you owe a 
copay for your visit, however you do dispute that you owe two copays for one visit. The Plan denied your 
request. The Plan says this claim was processed correctly per the plan 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). Your contract with the Plan clearly says that you must pay $110 
copayment for each Medicare covered radiological diagnostic service performed in a physician's office or at a 
free-standing facility (such as a radiology center or medical clinic).  
 
You have been asked to pay $220 copayment for the CT scans. The CT scans fall within the outpatient 
diagnostic tests and therapeutic services and supplies 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 computed tomography, thoracic spine (72129) and computed tomography, lumbar spine (72132) 
provided April 17, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve LTACH services. 
 
You asked the Plan to pre-approve the LTACH services. You say that the stay is medically necessary. The Plan 
denied your request. The Plan says the stay is not medically necessary. 
 
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 the patient appears to be improving but requires additional short term acute care 
services, which can safely be administered in the current setting. The patient does not require services at the 
LTACH that are not already available at the current setting. There are no services at the LTACH that the 
patient requires that are not already available and covered at the current setting. Therefore, this request for 
LTACH services will be considered not medically necessary. Transfer to a lower level of care may be 
considered soon. 
 
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 LTACH services.
Appeal type: Imaging
Decision: Partially Favorable

 
We decided that the Plan has to pre-approve a CT scan of the neck. We decided that the Plan does not have to 
pre-approve a CT scan of the chest.  
 
You asked the Plan to pre-approve a CT scan of the neck. You say that the services are necessary. The Plan 
says that based on the documentation provided, coverage criteria has not been met. 
 
We decided that the Plan has to pre-approve a CT scan of the neck. We asked our physician reviewer to 
carefully review the case file and apply the relevant Medicare rules to determine if the Part C Plan was correct 
in denying the request to pre-approve a CT scan of the neck. Our reviewer says that the requested service is 
considered medically reasonable and necessary in this case. Our physician reviewer found it is very reasonable 
to request a CT of the neck in the face of a 5 cm hard neck mass. Even if a biopsy were to be performed first, a 
CT would be necessary if the results were positive or negative based upon the symptoms and physical exam. 
 
 Therefore, we decided that the Plan has to pre-approve a CT scan of the neck.  
 
We also decided that the Plan does not have to pre-approve a CT scan of the chest. We asked our physician 
reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Part C Plan 
was correct in denying the request to pre-approve a CT scan of the chest. Our reviewer says that the requested 
service is not considered medically reasonable and necessary in this case. Our physician reviewer found the 
rationale for the necessity of a repeat Chest CT 4 months after the previous scan is not explained in the 
records. Thus, medical necessity of the repeat CT of the chest is not established. 
 
 Therefore, we decided that the Plan does not have to pre-approve a CT scan of the chest. 
 
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: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve replacement cover for wheelchair seat cushion or back 
cushion, each (CPT Code E2619). 
 
You asked the Plan to pre-approve the item. You say that you are requesting review of denial of services. The 
Plan denied your request. The Plan says this item is not considered to be primarily medical in nature and as 
such are not covered by Medicare. 
 
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 replacement cover for wheelchair seat cushion or back 
cushion, each (CPT Code E2619).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for knee orthosis and suspension sleeve provided on June 20, 
2020. 
 
You asked the Plan to pay for knee orthosis (L1833LT) and suspension sleeve (L2397LT). You say that the 
orthoses were medically necessary. The Plan denied your request. The Plan says the orthoses are not supported 
in the medical records received. 
 
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 knee orthosis (L1833LT) and suspension 
sleeve (L2397LT). Our reviewer says that the orthoses were not medically necessary. Our physician reviewer 
found the documentation in the case file does not support that the requested knee orthoses with sleeves were 
medically reasonable and necessary for the enrollee in this case, according to the coverage criteria established 
by the LCD. There is no documentation of recent injury to, or recent surgical procedure on, either of the 
enrollee's knees, and there is insufficient credible objective documentation of joint laxity.  
The item coded L2397 (sleeve) is not separately payable when the base item is not covered. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of knee orthosis (L1833LT) and suspension sleeve (L2397LT) have not been met. 
 
 
Therefore, we decided that the Plan does not have to pay for knee orthosis and suspension sleeve provided on 
June 20, 2020.
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to waive the copayment for the office visit provided on February 21, 2020. 
 
You asked the Plan to waive the copayment for the office visit. You say that the service provided was a 
preventive colonoscopy not a specialist visit. You say that the coverage decision should be changed. The Plan 
denied your request. The Plan says that the copayment applied correctly. 
 
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and 
diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or 
payment. 
 
The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their 
decision to deny your request. The diagnosis code on the claim is for an encounter for a screening for 
malignant neoplasm of colon. There were no medical records submitted to support that an office visit was 
provided instead of a screening colonoscopy. Therefore, we decided that the Plan has to waive the copayment 
for the office visit provided on February 21, 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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a specialist visit provided on June 19, 2020. 
 
You asked the Plan to waive the copayment for a specialist visit. You say that the visit should not warrant a 
copayment because the doctor came out and said the lab work was good and that was it. The Plan denied your 
request. The Plan says the claims were processed correctly and you are being charged the correct amount. 
 
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 $40 
copayment for each specialist visit.  
 
You have been asked to pay a $40 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 provided on June 19, 2020.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the x-ray services coded 73630 provided on June 24, 2020. 
 
You asked the Plan to pay for the x-ray services. You say that you would like the plan to reconsider their 
denial. The Plan denied your request. The Plan says the services were billed incorrectly. 
 
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 73630 is radiologic examination, foot; complete, 
minimum of 3 views. 
 
We find that CPT code 73630 is not supported in the medical record. Specifically, this service was not billed 
with a valid provider type. Based on this information, we decided that Medicare rules for coverage of the x-ray 
services have not been met. Therefore, we decided that the Plan does not have to pay for the x-ray services 
coded 73630 provided on June 24, 2020.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the medical services provided to the enrollee by an out-of-
network provider on August 1, 2020. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the services were not 
approved in advance. 
 
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 the enrollee by an out-of-network provider 
on August 1, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the CardioMEMS remote monitoring device for the 
enrollee. 
 
You asked the Plan to pre-approve the device. You say that this is medically necessary. The Plan denied your 
request. The Plan says this is considered experimental and investigational. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the device. Our reviewer says that the 
requested device is 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 randomized prospective 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. The device 
should still be considered experimental and 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 the device have not been met. Therefore, we decided that the Plan does not have 
to pre-approve the CardioMEMS remote monitoring device for the enrollee.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pay for home infusion therapy (S9328) provided on March 19, 2020, 
through April 30, 2020. 
 
You asked the Plan to pay for the home infusion therapy. You say that you would like reconsideration because 
this is not durable medical equipment and was not delivered to the member's home. The Plan denied your 
request. The Plan says S codes are not covered by Original Medicare. 
 
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 S9328 is not supported in the record. Specifically, per the Physician Fee Schedule, CPT 
code S9328 has a status indicator of I. This means that CPT code S9328 is not valid for Medicare purposes. 
Based on this information, we decided that Medicare rules for coverage of the home infusion therapy have not 
been met. Therefore, we decided that the Plan does not have to pay for home infusion therapy (S9328) 
provided on March 19, 2020, through April 30, 2020.