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

 
We decided that the Plan does not have to pre-approve gradient compression stocking/sleeve (CPT Code 
A6549). 
 
You asked the Plan to pre-approve the compression stockings. You say that the enrollee is using the gradient 
compression stockings for lymphedema. The Plan denied your request. The Plan says Medicare will not pay for 
compression stocking/wraps for lymphedema. 
 
The Plan must follow Medicare rules. Medicare rules say that compression stockings described by code A6549 
are covered only when they are used to treat an open venous stasis ulcer. Medicare rules also say that 
compression bandages and gradient compression wraps are covered only when they are used as dressings over 
a qualifying wound. 
 
 
 
 
The record does not show that you have open venous stasis ulcers or a qualifying wound. This means that you 
do not have a medical condition for which compression stockings can be covered or paid for by Medicare. 
Therefore, we decided that the Plan does not have to pre-approve gradient compression stocking/sleeve (CPT 
Code A6549).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the medical services to be provided by an out-of-
network provider. 
 
You asked the Plan to pre-approve the medical services. You say that nothing in-network is working 
adequately. The Plan denied your request. The Plan says appropriate care is available within the Plan. 
 
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 items/services at issue in this appeal. We found no exception that would require 
the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve 
the medical services to be provided by an out-of-network provider.
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 skilled nursing facility is not able to properly 
provide what you need. You also say that if you are able to go to a rehabilitation hospital, your recovery will be 
successful and at a much quicker rate. The Plan denied your request. The Plan says the IRF admission does not 
meet the requirements for approval. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described above. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found the records do not indicate that there are significant, or complex medical/nursing 
issues that could not be addressed at a lower level of care. Our reviewer found that you require some assistance 
for certain activities of daily living, but a less intensive, longer duration of therapy will allow for measurable 
gains to be attained within a reasonable, and predicted period. An IRF intensity is not warranted. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute IRF admission and services.
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 a skilled nursing level of care is 
unacceptable for the enrollee. You also say that the enrollee requires mid-to-long term acute care. The Plan 
denied your request. The Plan says the LTACH services that were requested do not meet the requirements for 
approval. 
 
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 enrollee does not require any services at the LTACH that are not already 
available at the current facility. Our reviewer found that there are no services at the LTACH that the enrollee 
requires that the current facility does not already have available and covered. Our physician reviewer also 
found that ongoing acute care services at the current facility appear to be most appropriate at this time. Transfer 
to a lower level of care may be appropriate at a later date. 
 
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: 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 submitted clinical records for review. The Plan denied your 
request. The Plan says care can be received in another setting. 
 
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 that there are no complex nursing or rehabilitation needs. Our reviewer says that the 
medical records support a need for physical and occupational therapy but it does not support a need for an 
intensive rehabilitation therapy program. 
 
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: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the medical services provided to you by an out-of-network 
provider on July 22, 2019. 
 
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 you by an out-of-network provider on July 
22, 2019.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to waive the cost sharing for injections provided on January 13, 2020 
and March 10, 2020. 
 
You asked the Plan to waive the cost sharing for injections. You say that you were not told how much the 
injections would cost. The Plan denied your request. The Plan says the coinsurance 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 20% 
coinsurance for in-network Medicare-covered Part B chemotherapy and prescription drugs and a $30 
copayment for each Medicare-covered visit with an in-network specialist. 
 
The allowed amount of the claim is $1,226, resulting in a coinsurance obligation of $245.20 per each of two 
injections. You have also been asked to pay a $30 copayment per each of two specialist visits. Therefore, your 
total cost sharing responsibility is $550.40.  
 
Injections fall within the Medicare Part B prescription drugs benefit category. Specialist visits fall 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 cost sharing for injections provided on January 13, 2020 and March 10, 2020.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the drug testing coded G0480 provided on November 4, 
2019. 
 
You asked the Plan to pay for the drug testing. 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 supported by the documentation. 
 
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 G0480 is drug test(s), definitive, utilizing (1) drug 
identification methods able to identify individual drugs and distinguish between structural isomers (but not 
necessarily stereoisomers), including, but not limited to gc/ms (any type, single or tandem) and lc/ms (any type, 
single or tandem and excluding immunoassays (e.g., ia, eia, elisa, emit, fpia) and enzymatic methods (e.g., 
alcohol dehydrogenase)), (2) stable isotope or other universally recognized internal standards in all samples 
(e.g., to control for matrix effects, interferences and variations in signal strength), and (3) method or drug-
specific calibration and matrix-matched quality control material (e.g., to control for instrument variations and 
mass spectral drift); qualitative or quantitative, all sources, includes specimen validity testing, per day; 1-7 drug 
class(es), including metabolite(s) if performed. 
 
We find that CPT code G0480 is not supported in the medical record. Specifically, this service was billed with 
a similar service (code G0481) provided by the same provider on the same day. G0481 is a component of 
column 1 code G0480 and only code G0481 will be reimbursed. Based on this information, we decided that 
Medicare rules for coverage of the drug testing have not been met. Therefore, we decided that the Plan does not 
have to pay for the drug testing coded G0480 provided on November 4, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the 2 additional resin-based composites (codes D2330 and 
D2331), orthodontic retention, and additional intraoral periapical x-ray provided From January 15, 2020 to 
April 27, 2020. 
 
You asked the Plan to pay for the orthodontic retention, resin-based composites (codes D2330 and D2331), and 
additional intraoral periapical x-ray. You say that you contacted the Plan prior to having these services 
rendered, to make sure that the dentist was in network and you would be covered. You also say that you do not 
feel the denial of these services was your fault. The Plan denied your request. The Plan says orthodontic 
retention is not a covered benefit. The Plan also says that your benefits for resin-based composites and intraoral 
x-rays have been satisfied and the frequency limitations have been exceeded. 
 
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, orthodontic retention not among those 
covered under this benefit. The Plan contract says that intraoral x-rays are limited to one procedure per 
calendar year, and restorations (fillings) are limited to two procedures per calendar year. The record shows that 
you received 4 resin-based composites on March 3, 2020, two of which were covered by the Plan, and your 
restorations benefit has been exhausted. The record also shows that you received a first intraoral periapical x-
ray and an additional intraoral periapical x-ray on April 27, 2020, the first intraoral periapical x-ray was 
covered by the Plan, and your intraoral x-rays benefit has been exhausted. Therefore, we decided that the Plan 
does not have to pay for the 2 additional resin-based composites (codes D2330 and D2331), orthodontic 
retention, and additional intraoral periapical x-ray provided From January 15, 2020 to April 27, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the lumbar-sacral orthosis and the shoulder-elbow-wrist-
hand orthosis provided on April 3, 2020. 
 
You asked the Plan to pay for the lumbar-sacral orthosis (L0650) and the shoulder-elbow-wrist-hand orthosis 
(L3960). You say that the orthoses were medically necessary. The Plan denied your request. The Plan says the 
orthoses were not 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 pay for the lumbar-sacral orthosis (L0650) and the 
shoulder-elbow-wrist-hand orthosis (L3960). Our reviewer says that the orthoses were not medically necessary. 
Our physician reviewer found the enrollee's chief complaints were back pain and shoulder pain. The available 
documentation in the case file does not support that the requested lumbar-sacral orthosis was medically 
reasonable and necessary for the enrollee in this case, according to the coverage criteria established by the 
LCD.  
 
An appropriate history and a physical examination of the back would reasonably be required to adequately 
assess whether the coverage criteria for a lumbar sacral orthosis have been met. The documentation does not 
support that the lumbar-sacral orthosis was prescribed for one or more of the covered indications in this case, as 
there is insufficient documentation of a credible physical examination of the back. 
 
The documentation in the case file does not support that the requested shoulder/arm orthosis was medically 
reasonable and necessary for the enrollee in this case. A physical examination of the shoulder would reasonably 
be required to adequately assess whether the shoulder/arm orthosis was medically necessary for an enrollee. 
The documentation does not support that the orthosis was medically reasonable and necessary for the enrollee 
in this case, as there is insufficient documentation of a credible physical examination of the shoulder. 
 
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 lumbar-sacral orthosis (L0650) and the shoulder-elbow-wrist-hand orthosis 
(L3960) have not been met. Therefore, we decided that the Plan does not have to pay for the lumbar-sacral 
orthosis and the shoulder-elbow-wrist-hand orthosis provided on April 3, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an IRF admission provided from November 21, 2019 to 
December 4, 2019. 
 
You asked the Plan to pay for the IRF admission. The Plan denied your request. The Plan says generally the 
enrollee must receive care from a network provider. In most cases, care the enrollee receives from a non-
network provider will not be covered. 
 
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 
IRF admission. 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 an IRF admission provided from November 21, 2019 to 
December 4, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a wig (A9282) provided on  February 24, 2020. 
 
You asked the Plan to pay for a wig. You say that you were told this would be covered. The Plan denied your 
request. The Plan says this is not covered by Medicare or the Plan. 
 
Medicare may pay for items which either meet the definition of DME or a prosthesis when these items are 
ordered by a physician. The Plan follows these same rules. 
 
In this case, although the wig may be appropriate, it does not meet the definition of the above benefit 
categories. It is not considered DME because it does not directly treat a medical condition. It does not meet the 
Medicare definition of a prosthetic because it does not replace an internal body organ or attached tissue. As 
such, it is noncovered by Medicare. Furthermore, the Plan does not offer a supplemental benefit which would 
provide coverage for a wig. Therefore, we decided that the Plan does not have to pay for a wig (A9282) 
provided on  February 24, 2020.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the self-administered drugs provided from March 17, 2020 to 
March 20, 2020. 
 
You asked the Plan to pay for the self-administered drugs. You say that you were not informed by the hospital 
staff that the charges for these drugs would be your responsibility. The Plan denied your request. The Plan says 
self-administered medications are not covered under Part B. 
 
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-
administered drugs. The self-administered drugs requested here are not among the types which are covered by 
Medicare Part B. Therefore, we decided that the Plan does not have to pay for the self-administered drugs 
provided from March 17, 2020 to March 20, 2020.  
 
Benefits for the self-administered drugs may be available under Medicare Part D. Contact the Plan that 
administers Part D benefits for further information concerning any benefits and appeal rights.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayments for emergency room visits (99283) on April 
26 and April 28, 2020. We also decided that the Plan does not have to pay for self-administered drugs received 
in the emergency room on April 26, 2020. 
 
You asked the Plan to waive the copayments for emergency room visits and to pay for self-administered drugs. 
You say that you cannot afford extra expenses at this time. The Plan denied your request. The Plan says the 
correct copayments were applied. 
 
Regarding the request for the Plan to waive the copayment for emergency room visits: 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 $90 copayment for emergency 
services provided at the emergency room.  
 
You have been asked to pay a $90 copayment for each emergency room visit. An emergency room visit falls 
within the "Emergency care" 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 emergency 
room visits (99283) on April 26 and April 28, 2020.  
 
Regarding the request for the Plan to pay for self-administered drugs: the Plan must follow Medicare rules. The 
rules say that Medicare Part B generally does not pay for self-administered drugs. The self-administered drugs 
requested here are not among the types which are covered by Medicare Part B. Therefore, we decided that the 
Plan does not have to pay for self-administered drugs received in the emergency room on April 26, 2020. 
 
Benefits for self-administered drugs may be available under Medicare Part D. Contact the Plan that administers 
Part D benefits for further information concerning any benefits and appeal rights.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for home infusion therapy services provided from September 10, 
2019 to February 13, 2020. 
 
You asked the Plan to pay for the home infusion therapy services. You say that the Plan should pay this claim. 
The Plan denied your request. The Plan says this code is not valid for Medicare purposes. 
 
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 S9328 is home infusion therapy, implanted pump pain 
management infusion; administrative services, professional pharmacy services, care coordination, and all 
necessary supplies and equipment (drugs and nursing visits coded separately), per diem. 
 
We find that CPT code S9328 is not a valid code for Medicare purposes. S codes are unique temporary codes 
established by BCBSA and HIAA for private payor use. They are not valid nor payable by Medicare. 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 home infusion therapy services have not been met. Therefore, we decided 
that the Plan does not have to pay for home infusion therapy services provided from September 10, 2019 to 
February 13, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Freestyle Libre continuous glucose monitor. 
 
You asked the Plan to pre-approve the services. You say that this is medically necessary. The Plan denied your 
request. The Plan says there was no documentation showing testing four 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 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 services. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found you are on only once daily insulin, and do not meet the criteria for this monitor. 
 
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 services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a Freestyle Libre continuous glucose monitor.