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

 
We decided that the Plan does not have to pre-approve a pneumatic compression device (E0652). 
 
You asked the Plan to pre-approve a pneumatic compression device. You say that you are appealing regarding 
the denial of coverage for the Flexitouch pneumatic compression device. The Plan denied your request. The 
Plan says the enrollee does not meet the LCD criteria for an advanced lymphedema pump as there is no failed 
four week trial of a basic pneumatic compression device of either E0650 or E0651. 
 
 The Plan follows Medicare rules. The rules state that a PCD coded as E0652 is covered for the treatment of 
lymphedema extending onto the chest, trunk and/or abdomen after a four-week trial of conservative therapy 
demonstrating failed response to treatment with an E0650 or E0651. At least four weeks of regular, daily, 
multiple-hour home usage of the E0650 or E0651 is required. 
 
We looked at the file and Medicare rules. Based on this information we decided that Medicare rules for 
coverage of the PCD have not been met. Specifically, the record does not show that the enrollee had at least 
four weeks of regular, daily, multiple-hour home usage of the E0650 or E0651 after careful, in-person fitting, 
training and supervision by a technician who is skilled in and who regularly and successfully uses the appliance 
provided. Therefore, we decided that the Plan does not have to pre-approve a pneumatic compression device 
(E0652).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab work provided on June 22, 2020 by an out of network 
(OON) provider. 
 
You asked the Plan to pay for lab work. You say that you would like this claim reprocessed and paid. The Plan 
denied your request. The Plan says there are in-network providers available who can provide these services. 
The Plan says that prior authorization was not obtained. 
 
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 lab work provided on June 22, 2020 by an out of 
network (OON) provider.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home health services provided to the enrollee from 
February 10, 2020 to June 9, 2020. 
 
You asked the Plan to pay for home health 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. The rules say that certain data elements on the RAP and the claim must 
be completed for home health care services to be covered. 
 
We looked at the claim submitted, the file and the Medicare rules. Based on this information, we decided that 
Medicare rules for completing the claim for home health services have not been met. Specifically, the claims 
were not submitted with a valid HIPPS (Health Insurance Prospective Payment System) code required for 
processing. Therefore, we decided that the Plan does not have to pay for the home health services provided to 
the enrollee from February 10, 2020 to June 9, 2020.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services provided on May 19, 2020. 
 
You asked the Plan to pay for the laboratory services. You say that you would like reconsideration because you 
are not given any information about the member's insurance requirements, limitations or conditions. The Plan 
denied your request. The Plan says this testing is not covered for screening purposes. 
 
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 test at issue in this appeal, the laboratory services, was requested solely for screening purposes. Medicare 
does not cover this test solely for screening purposes. Therefore, we decided that the Plan does not have to pay 
for the laboratory services provided on May 19, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve inpatient admission for spinal surgery. 
 
You asked the Plan to pre-approve inpatient admission for spinal surgery. You say that the services are 
necessary. The Plan denied your request. The Plan says medical necessity has not been established. Therefore, 
coverage criteria has not been met. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve inpatient admission for spinal surgery. 
Our reviewer says that the requested items/services are not considered medically reasonable and necessary in 
this case. Our physician reviewer found the criteria for fusion has not been met. There is no documented 
instability, fracture, or lesion. Surgery is not needed. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of inpatient admission for spinal surgery have not been met. Therefore, we decided 
that the Plan does not have to pre-approve inpatient admission for spinal surgery.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a diagnostic colonoscopy provided by a 
participating provider on July 10, 2020. 
 
You asked the Plan to waive the copayment for a diagnostic colonoscopy. You say that you thought this would 
be covered 100%. The Plan denied your request. The Plan says the correct copayment has been 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 a $300 
copayment for outpatient surgery.  
 
You have been asked to pay a $300 copayment for a diagnostic colonoscopy. Evidence was provided that 
polyps were removed. The rules say that, if during the course of the screening colonoscopy, a lesion or growth 
is detected which results in a biopsy or removal of the growth, the appropriate diagnostic procedure classified 
as a colonoscopy with biopsy or removal should be billed. a diagnostic colonoscopy falls within the outpatient 
surgery 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 diagnostic colonoscopy 
provided by a participating provider on July 10, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. 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 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 
complexity of the patient's nursing, medical and rehabilitation needs does not require an acute hospital inpatient stay with 
an interdisciplinary approach to rehabilitation care. The patient was admitted for treated of peripheral artery disease of the 
left leg. Medical conditions are stable. There are medical needs requiring inpatient admission. There are no complex 
nursing or rehabilitation needs. The patient does not require treatment by multiple therapies, including either physical 
therapy or occupational therapy, and an intensive rehabilitation therapy program. While the medical record documents a 
need for physical and occupational therapy, it does not document a need for an intensive rehabilitation program. There is 
not a reasonable expectation that this patient will be able to fully participate in and benefit from the intensive 
rehabilitation therapy program provided in an IRF. 
 
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 
IRF admission and services.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayments for an echocardiography procedure (93306) 
and an ultrasound of veins of the extremities (93970) performed on July 13, 2020. 
 
You asked the Plan to waive the copayments for an echocardiography procedure and an ultrasound of veins of 
the extremities. You say that you never had to pay this before. The Plan denied your request. The Plan says the 
correct copayments were 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 a $25 
copayment for carotid or peripheral vascular ultrasound and a $20 copayment for most X-rays and ultrasounds 
except as specified.  
 
You have been asked to pay a $20 copayment for an echocardiography procedure and a $25 copayment for an 
ultrasound of veins of the extremities. An echocardiography procedure and an ultrasound of veins of the 
extremities 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 copayments for an echocardiography procedure (93306) and an ultrasound 
of veins of the extremities (93970) performed on July 13, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the chiropractic services rendered on March 19, 2019 to June 
18, 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 services are not covered. 
 
The Plan must follow Medicare rules. The rules say that the only chiropractic service Medicare covers is 
manual manipulation of the spine to correct a subluxation.  
 
The records show that the service at issue is not manual manipulation of the spine. The file shows that the 
provider billed procedure codes 97110 (therapeutic exercises), 98943 (extraspinal manipulation), 97010 (hot or 
cold packs therapy), G0283 (electrical stimulation), and 97140 (manual therapy). Therefore, we decided that 
the Plan does not have to pay for the chiropractic services rendered on March 19, 2019 to June 18, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for a breast prosthesis (L8030) and a 
mastectomy bra (L8000) received on April 25, 2019. 
 
You asked the Plan to waive the coinsurance for a breast prosthesis and a mastectomy bra. You say that your 
responsibility was paid in full based on the claim that was initially submitted. The Plan denied your request. 
The Plan says the correct coinsurance 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 and related supplies.  
 
You have been asked to pay $106, or 20% of the Medicare-allowed amount of $530, for a breast prosthesis and 
a mastectomy bra. A breast prosthesis and a mastectomy bra fall within the "Durable medical equipment 
(DME) and related 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 coinsurance for a breast 
prosthesis (L8030) and a mastectomy bra (L8000) received on April 25, 2019.  
 
Your complaint about receiving an updated bill for a claim that is over a year old is not a valid appeal for 
medical coverage. This part of your complaint is a grievance that must be answered by the Plan. Medicare does 
not permit us to make a decision about these types of complaints.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for continuous intraoperative neurophysiology monitoring 
provided on August 6, 2019. 
 
You asked the Plan to pay for continuous intraoperative neurophysiology monitoring (G0453). You say that the 
claims was timely. The Plan denied your request. The Plan says the claim was untimely. 
 
The Plan follows Medicare rules. The rules say that claims for services furnished on or after January 1, 2010, 
must be filed no later than one calendar year after the date of service. 
 
The record shows that a claim for continuous intraoperative neurophysiology monitoring (G0453) was not filed 
until August 6, 2019. This means that, 366 days, more than one calendar year from the date of service had 
passed before a claim was filed. Therefore, we decided that the Plan does not have to pay for continuous 
intraoperative neurophysiology monitoring provided on August 6, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for a bevacizumab injection (J9035) provided on April 7, 2020. 
 
You asked the Plan to pay for a bevacizumab injection. You say that this was billed correctly. The Plan denied 
your request. The Plan says this should have been reported with J7999. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. providers should report HCPCS code J7999 for 
ophthalmological use of bevacizumab. 
 
We find that CPT code J9035 is not supported in the medical record. Specifically, this was an ophthalmological 
use of bevacizumab. Based on this information, we decided that Medicare rules for coverage of a bevacizumab 
injection have not been met. Therefore, we decided that the Plan does not have to pay for a bevacizumab 
injection (J9035) provided on April 7, 2020.
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 it is felt that IRF would provide better outcomes than 
SNF or return to home. The Plan denied your request. The Plan says the enrollee's medical condition is stable 
and intensive rehab is not required. 
 
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 complexity of the patient's nursing, medical and rehabilitation needs does not 
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The patient was 
admitted for a cough and falls at home. She had been recently discharged from a skilled nursing facility, where 
she had been admitted after a stroke in November 2020. She was evaluated by neurology who concluded that 
she had dense persistent left side hemiplegia after the earlier stroke. She received antibiotics in the Emergency 
Department for possible pneumonia. These were discontinued when further evaluation determined that there 
was no new diagnosis of pneumonia. Medical conditions are stable. There are no medical needs requiring 
inpatient admission. There are no complex nursing or rehabilitation needs. 
 
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: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for radiology services provided by a 
participating provider on June 16, 2020, to August 29, 2020. 
 
You asked the Plan to waive the copayment for radiology services. You say that you do not know why you are 
being charged different amounts. The Plan denied your request. The Plan says the correct copayment has been 
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 a $150 
copayment for outpatient diagnostic tests/in-network/radiology services.  
 
You have been asked to pay less than a $150 copayment for radiology services. The total copayment amount is 
$,350 ($150 x 29 visits = $4,350). You are being asked to pay a lesser amount of $3,758,42. Radiology services 
fall within the outpatient diagnostic tests/in-network/radiology services 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 radiology services provided by a participating provider on June 16, 
2020, to August 29, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for lab work provided on February 13, 2020 by an out of 
network (OON) provider. 
 
You asked the Plan to pay for lab work. 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. 
 
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 lab work provided on February 13, 2020 by an out 
of network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for hearing aids (V5140) purchased on May 1, 2020. 
 
You asked the Plan to pay for hearing aids. You say that the Plan told you that they would help you with $750 
for each ear. The Plan denied your request. The Plan says rules for payment have not been met. 
 
Medicare does not pay for hearing aids or related services. However, the Plan offers a hearing aid benefit that 
exceeds Medicare coverage. For that reason, the plan's coverage rules apply in this case. The Plan pays for 
hearing aids only when you receive services from a network hearing aid provider.  
 
We looked at the case file and the Plan's rules. The case record shows that you purchased hearing aids from an 
out of network provider. Based on this information, we decided that the Plan's rules for coverage of hearing 
aids have not been met. Therefore, we decided that the Plan does not have to pay for hearing aids (V5140) 
purchased on May 1, 2020.
Appeal type: Hospice
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the lower extremity study provided on June 19, 2020. 
 
You asked the Plan to pay for the physician service. You say that the service rendered to the enrollee was not 
related to the diagnosis associated with the enrollee's hospice enrollment. The Plan denied your request. The 
Plan says the enrollee's claim would be covered under Original Medicare as it is responsible for coverage of 
Part B benefits starting on the date of election until the last day of the month in which hospice is revoked. The 
Plan also says it is the provider's responsibility to verify the member's coverage before rendering services and 
to know proper billing procedures for a Medicare Advantage member on hospice. 
 
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 date of service at issue in this appeal. Therefore, 
we decided that the Plan does not have to pay for the lower extremity study provided on June 19, 2020.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an ultrasound of the extracranial arteries 
(93880) performed on July 15, 2020. 
 
You asked the Plan to waive the copayment for an ultrasound of the extracranial arteries. You say that you 
have had exactly the same scan done before with a lower copayment. The Plan denied your request. The Plan 
says the correct copayment 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 in 2020 you must pay a 
$100 copayment for each Medicare-covered radiological diagnostic service, not including X-rays.  
 
You have been asked to pay a $100 copayment for an ultrasound of the extracranial arteries. An ultrasound of 
the extracranial arteries falls 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 an ultrasound of the extracranial 
arteries (93880) performed on July 15, 2020.