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

 
We decided that the Plan does not have to pre-approve a CardioMEMs device. 
 
You asked the Plan to pre-approve the CardioMEMs device. You say that the enrollee has heart failure and the 
requested device is needed to better manage her condition. The Plan denied your request. The Plan says the 
requested device is experimental and the enrollee is not in a trial. 
 
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 CardioMEMs device. Our reviewer 
says that the requested device is not medically reasonable and necessary in this case. Our physician reviewer 
found the American College of Cardiology and the American Heart Association have not specifically addressed 
outpatient wireless implantable pulmonary artery pressure monitoring. However, there has been no established 
role for routine or periodic invasive hemodynamic measurements in the management of heart failure. Most 
drugs used for the treatment of heart failure are prescribed on the basis of their ability to improve symptoms or 
survival rather than their effect on hemodynamic variables. The initial and target doses of these drugs are 
generally selected on the basis of controlled trial experience rather than changes produced in cardiac output or 
pulmonary capillary wedge pressure. Although recent systematic reviews and meta analyses have shown a 
positive effect on heart failure-related admissions, mortality rates and all-cause mortality rates, the bulk of the 
literature consists of low-quality and inconsistent evidence about the beneficial effects of remote patient 
monitoring. More specifically, though better evidence from randomized control trials has been unfavorable, it 
still stands in contrast to the favorable evidence gained from non-randomized trials. 
 
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 CardioMEMs device have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a CardioMEMs device.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve compression stockings identified with code A6549. 
 
You asked the Plan to pre-approve the compression stockings. You say that the claim should be paid. The Plan 
denied your request. The Plan says compression stockings are not a covered benefit. 
 
The Plan must follow Medicare rules. The rules say that compression stockings described by code A6549 are 
noncovered because they do not meet the statutory definition of a surgical dressing.  
 
Although this item may be appropriate, it does not fall into a covered benefit category and cannot be paid for 
by Medicare or the Plan. Therefore, we decided that the Plan does not have to pre-approve compression 
stockings identified with code A6549.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayments for actinotherapy provided from May 14, 
2020 to June 24, 2020. 
 
You asked the Plan to waive the copayments for actinotherapy. You say that you disagree with the charges. 
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 $45 
copayment for specialist services. 
 
You received actinotherapy from May 14, 2020 to June 24, 2020 for a total of 4 visits. Therefore, you are 
responsible to pay the total allowed amount of $86.60, which is less than the total copayment amount.   
 
You have been asked to pay $86.60 for actinotherapy. Actinotherapy 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 copayments 
for actinotherapy provided from May 14, 2020 to June 24, 2020.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a computed tomography (CT) scan of the chest. 
 
You asked the Plan to pre-approve these services. You say that the services are medically necessary. 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 a history of tobacco 
use and a history of chronic obstructive pulmonary disease with report of unusual lung findings (endobronchial 
debris, most likely mucus from a previous CT chest from May 18, 2020. Although a minor finding on the prior 
CT was new, it was likely mucus and had no suspicious qualities to justify repeat CT three months later. The 
radiologist also reported no significant changes. There were no other clinical indications for this test at the time 
it was ordered. Therefore, this request for CT chest will be considered not 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 computed tomography (CT) scan of the chest.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the limited oral evaluation provided on June 1, 2020. 
 
You asked the Plan to pay for the limited oral evaluation. You say that the office did a limited oral evaluation 
when they knew it wasn't covered. You say that  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 pay for the 
limited oral evaluation provided on June 1, 2020.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for home health services provided to the enrollee from February 
5, 2020, to February 26, 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 this was billed with an incorrect type of bill code. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly.  
 
We find that the denied codes are not supported in the medical records. This was billed with type of bill 323, 
which is not allowed under Medicare billing. 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 home 
health services provided to the enrollee from February 5, 2020, to February 26, 2020.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services (88305, 88312) rendered by the out of 
network (OON) provider on May 27, 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 laboratory services (88305, 88312) rendered by the out of network (OON) provider 
on May 27, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the services rendered from July 26, 2019 to August 6, 2019. 
 
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says the provider is not Medicare-certified. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for services only when they are 
furnished by a provider or supplier enrolled in the Medicare program. 
 
The file shows that the provider was not Medicare-certified during the dates of service at issue in this appeal. 
Therefore, we decided that the Plan does not have to pay for the services rendered from July 26, 2019 to 
August 6, 2019.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ambulance services provided on March 8, 2020. 
 
You asked the Plan to pay for the ambulance services. You say that you were following the COVID executive 
order for treatment in place. The Plan denied your request. The Plan says these services are not a covered 
benefit. 
 
The Plan must follow Medicare rules. The rules say that Medicare does not pay for ambulance services when 
there is no transport.  
 
The ambulance company did not provide transport services on March 8, 2020. The ambulance benefit is a 
transportation benefit. When there is no transport, neither Medicare nor the Plan pays for the services provided. 
Therefore, we decided that the Plan does not have to pay for the ambulance services provided on March 8, 
2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay forthe parenteral nutrition provided from December 4, 2019 to December 6, 2019.You asked the Plan to pay forthe parenteral nutrition. You say that you would like the plan to reconsider their denial.The Plan denied your request. The Plan says an itemized shipping/billing invoice was not provided.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. Review of the fileshows that an itemized shipping/billing invoice to indicate the billed supply or proof of delivery for the billed dates of service was not provided. 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 forthe parenteral nutrition provided from December 4, 2019 to December 6, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for skilled nursing services provided on May 22, 2019 by an out 
of network (OON) provider. 
 
You asked the Plan to pay for skilled nursing services. You say that it is the responsibility of the facility to 
obtain prior authorization. The Plan denied your request. The Plan says prior authorization was not obtained by 
the provider or facility. 
 
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 
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 skilled nursing services provided on May 22, 2019 
by an out of network (OON) provider.
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 8, 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 8, 2020.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for x-rays (72070, 72114, 72170) provided on February 4, 2020. 
 
You asked the Plan to pay for the x-rays. You say that the services were medically necessary. The Plan denied 
your request. The Plan says the services were not emergent or pre-authorized. There were network providers 
available. 
 
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 service 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 x-rays (72070, 72114, 72170) provided on February 4, 2020.
Appeal type: Other
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the BLS emergency ambulance service (A0429) and ground 
mileage (A0425) provided December 16, 2019. 
 
You asked the Plan to pay for the ambulance service. You say that you billed the hospice and they denied the 
claim stating the enrollee was discharged from hospice on the date of service. The Plan denied your request. 
The Plan says the enrollee enrolled in Hospice on June 11, 2019 and remained in Hospice until his date of 
death on December 17, 2019. Original Medicare would be responsible for payment of all Medicare covered 
services related or unrelated to the members terminal condition. 
 
Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice 
services. Medicare hospice pays for claims related to the terminal illness. The rules say that the Plan may direct 
the provider to bill Medicare directly for these services.  
 
The enrollee was under the Medicare hospice benefit for the dates of service at issue in this appeal. Therefore, 
we decided that the Plan does not have to pay for the BLS emergency ambulance service (A0429) and ground 
mileage (A0425) provided December 16, 2019.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pay for self-care/ home management training (97535) provided on 
April 14, 2020. 
 
You asked the Plan to pay for the self-care/home management training. You say that you would like 
reconsideration based on the records submitted. The Plan denied your request. The Plan says the documentation 
does not support that this service was performed on the billed date of service. 
 
The Plan must follow Medicare rules. Medicare rules say that for Medicare to consider coverage and payment 
for any item or service, the information submitted by the supplier or provider must corroborate the 
documentation in the beneficiary's medical documentation and confirm that Medicare coverage criteria have 
been met. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the self-care/home management training. have not been met. Specifically, the submitted 
documentation does not include the billed date of service. The record does not include sufficient information to 
determine whether payment is due and the amount of payment. Therefore, we decided that the Plan does not 
have to pay for self-care/ home management training (97535) provided on April 14, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for dental services provided on July 9, 2020. 
 
You asked the Plan to pay for dental services. You say that you had no choice but to see an out-of-network 
provider. You say that you are requesting coverage. The Plan denied your request. The Plan says out-of-
network dental 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, out-of-network dental services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for dental 
services provided on July 9, 2020.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for drug testing provided on March 17, 2020. 
 
You asked the Plan to pay for drug tests. You say that you are appealing with supporting documentation. The 
Plan denied your request. The Plan says the denial of payment for these services is correct, because the 
documentation does not support the Place of Service (POS) code billed on this claim. 
 
The Plan must follow Medicare rules. Medicare rules say that if an independent lab bills for services, the place 
where the sample was taken is reported as the Place of Service (POS).  
 
We looked at the file and Medicare rules. The documentation submitted shows that the sample for this testing 
was taken in an office setting, therefore the Place of Service (POS) code 81 ? indicating an independent 
laboratory setting ? is not appropriate for this claim. Based on this information, we decided that Medicare rules 
for coverage of drug tests have not been met. Therefore, we decided that the Plan does not have to pay for drug 
testing provided on March 17, 2020.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab tests provided by an out of network 
(OON) provider. 
 
You asked the Plan to pay for lab tests. You say that it is the provider's responsibility to obtain prior 
authorization. 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 the member's primary care 
physician did not refer these services. The Plan says that the referring provider is also out-of-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 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 lab tests provided by an out 
of network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the wrist/hand orthosis. 
 
You asked the Plan to pay for the wrist/hand orthosis. You say that you would like the plan to reconsider their 
denial. The Plan denied your request. The Plan says the item received is not a covered benefit. 
 
The plan must follow Medicare rules. The rules say that Medicare pays for services only when they are 
furnished by a provider or supplier enrolled in the Medicare program. 
 
Review of the file shows that the provider was not Medicare-certified for the date of service in this appeal. 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 wrist/hand orthosis.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the subsequent nursing facility care, per day (99309) 
rendered by the out of network (OON) provider on November 20, 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 subsequent nursing facility care, per day (99309) rendered by the out of network (OON) 
provider on November 20, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the hydration intravenous infusion services. 
 
You asked the Plan to pay for the hydration intravenous infusion services. You say that you would like the plan 
to reconsider their denial. The Plan denied your request. The Plan says the services billed are not 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, the fluid used to administer 
the drug(s) is incidental hydration and is not separately payable. Based on this information, we decided that 
Medicare rules for coverage of the hydration intravenous infusion services have not been met. Therefore, we 
decided that the Plan does not have to pay for the hydration intravenous infusion services.