Persius/hicric huggingface dataset:
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the lab services provided on July 23, 2019 by an out of
network (OON) provider.
You asked the Plan to pay for the OON services. You say that the test is used to determine best therapy options.
The Plan denied your request. The Plan says the services received 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 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 lab services provided on July 23, 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 Insertion tray without drainage bag and without catheter
(accessories only) (A4310), Indwelling catheter; foley type, two-way latex with coating (teflon, silicone,
silicone elastomer, or hydrophilic, etc.), each (A4338) and Bedside drainage bag, day or night, with or without
anti-reflux device, with or without tube, each (A4357) provided to the enrollee on December 20, 2019.
You asked the Plan to pay for the DME. You say that the claim should be paid. The Plan denied your request.
The Plan says the Medicare rules have not been met.
The Plan must follow Medicare rules. We looked at the file and Medicare rules. Based on this information, we
decided that Medicare rules for coverage of the DME have not been met. The services are not authorized
because they are a part-A benefit for skilled nursing facility (SNF) admissions and are included in the facility
PPS payment. The facility received Medicare part-A skilled nursing facility payment and is responsible to
provide all services and pay any and all vendors. After reassessing the entire situation, the result is that the
initial denial is upheld and the service is not authorized. Therefore, we decided that the Plan does not have to
pay for Insertion tray without drainage bag and without catheter (accessories only) (A4310), Indwelling
catheter; foley type, two-way latex with coating (teflon, silicone, silicone elastomer, or hydrophilic, etc.), each
(A4338) and Bedside drainage bag, day or night, with or without anti-reflux device, with or without tube, each
(A4357) provided to the enrollee on December 20, 2019.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for the mitomycin injection provided on
December 26, 2019, January 2, 2020 and January 10, 2020.
You asked the Plan to waive the coinsurance for the mitomycin injections. You say that the copayments are not
applicable. You say that you weren't informed of an amount you would be responsible for. The Plan denied
your request. The Plan says the coinsurance applied correctly.
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 chemotherapy drugs and 20% coinsurance for all other drugs covered under Medicare Part B
from an in-network provider.
You have been asked to pay a total of $421.20 for the mitomycin injections.
The mitomycin injections fall 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 coinsurance for the mitomycin injection provided on December 26, 2019, January 2,
2020 and January 10, 2020.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for X-rays (73502, 76499, Q0092) provided August 7, 2019.
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 records do not support the services billed.
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 codes 73502, 76499, & Q0092 are Radiologic examination,
hip, unilateral, with pelvis when performed; 2-3 views, Unlisted diagnostic radiographic procedure, and Set-up
of portable x-ray equipment.
We find that CPT codes 73502, 76499, & Q0092 are not supported in the medical record. Specifically, the
records provided do not include exam notes that support the services billed were provided. Based on this
information, we decided that Medicare rules for coverage of the x-rays have not been met. Therefore, we
decided that the Plan does not have to pay for X-rays (73502, 76499, Q0092) provided August 7, 2019.
Appeal type: Hospice
Decision: Unfavorable

We decided that the Plan does not have to pay for physician services provided to the enrollee on July 24, 2019.
You asked the Plan to pay for this service. You say that this claim should be paid. The Plan denied your
request. The Plan says the records show the enrollee was enrolled in hospice from June 22, 2019 through
December 6, 2019. In accordance with Medicare guidelines, the provider needs to bill Original Medicare, using
the proper modifiers, for services rendered on July 24, 2019. Per the regulations above, the 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. It is the providers responsibility to verify
the members 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 dates of service at issue in this appeal. Therefore, we decided that the Plan does not have to pay for
physician services provided to the enrollee on July 24, 2019.
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 the services are necessary. The Plan denied your
request. The Plan says based on the documentation provided, coverage criteria has not been met.
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 based on the provided medical records the enrollee is receiving necessary services
and is at an appropriate level of care in the acute care hospital. Continued care at this level is appropriate until
the enrollee is stable to transfer to a lower level of care such as an inpatient rehabilitation facility, a skilled
nursing facility, sub-acute rehabilitation facility or home with home health services.
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: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the dental services provided on December 12, 2019.
You asked the Plan to pay for the dental services. The Plan denied your request. The Plan says payment is
unable to be made for services provided by a dentist that has opted out of Medicare.
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.
We looked at the file, and Medicare rules. The documentation shows the provider at issue has opted out of
Medicare. Your plan does not cover dental services who have opted out, or has been excluded from Medicare.
Based on this information, we decided that the Plan's rules for coverage of the dental services have not been
met. Therefore, we decided that the Plan does not have to pay for the dental services provided on December 12,
2019.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pre-approve 18 home health aide visits.
You asked the Plan to pre-approve home health aide visits. You say that these services should be covered. The
Plan denied your request. The Plan says these services are not necessary because the enrollee has a caregiver
available.
The Plan must follow Medicare rules. The rules say that HHA services may be covered if it is medically
necessary for the enrollee to receive skilled nursing or therapy.
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 home health aide visits. Our reviewer
says that the requested services are not medically necessary at this time. Our physician reviewer found the
records do not show that the requested services are necessary or that the enrollee's private caregiver is not able
to provide all of the services needed for the enrollee's personal care.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of home health aide visits have not been met. Therefore, we decided that the Plan
does not have to pre-approve 18 home health aide visits.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the colonoscopy provided on December 17,
2019.
You asked the Plan to waive the copayment for the colonoscopy. You say that you are entitled to one free
colonoscopy. You say your doctor ordered the Cologuard diagnostic test which found blood in the stool thereby
necessitating the referral for the colonoscopy. The Plan denied your request. The Plan says you have been
charged the correct cost sharing 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 $200
copayment for each in-network Medicare-covered ambulatory surgical center visit.
You have been asked to pay a $200 copayment for the colonoscopy. The colonoscopy falls within the
"Outpatient surgery, including services provided at hospital outpatient facilities and ambulatory surgical
centers" benefit category. The record shows the colonoscopy was ordered due to blood in stools which makes
the colonoscopy diagnostic in nature.
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 the colonoscopy provided on December 17, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for bitewings - four radiographic images (D0274) provided on
November 18, 2019.
You asked the Plan to pay for the dental services. You say that you were unaware that only two bitewings were
covered by your supplemental dental plan. The Plan denied your request. The Plan says the service is not a
covered benefit under the plan.
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. The service is not listed in your EOC as a covered benefit; therefore,
the services are not covered. Your EOC states, 1 set of 2 bitewings per calendar year, limited to the following
codes: D0270 or D0272. Therefore, we decided that the Plan does not have to pay for bitewings - four
radiographic images (D0274) provided on November 18, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for chiropractic services provided on January 9, 2020.
You asked the Plan to pay for this service. You say that this service should be covered by the Plan. The Plan
denied your request. The Plan says services that are not related to manual manipulation of the spine 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. Therefore, we decided that the Plan does not have to pay for chiropractic
services provided on January 9, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the dental services provided on January 20, 2020, by an outof-
network provider.
You asked the Plan to pay for the dental services. You say that you did not know the provider was out-ofnetwork
until the work was over. The Plan denied your request. The Plan says services performed by an out-ofnetwork
provider are not covered.
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.
We looked at the file, and Medicare rules. Although plan benefits include extractions, they are not covered
when provided by an out-of-network dentist. Based on this information, we decided that the Plan's rules for
coverage of the dental services have not been met. Therefore, we decided that the Plan does not have to pay for
the dental services provided on January 20, 2020, by an out-of-network provider.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a duplex scan of extremity veins.
You asked the Plan to pre-approve the requested testing. You say that the enrollee has a history of deep vein
thrombosis, and is in severe pain.
The Plan denied your request. The Plan says in the absence of new findings, the medical necessity of a repeat
test cannot be established.
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 requested testing. Our physician
reviewer found that the enrollee has been having regular follow up visits. There is no suggestion in the
documentation that there was a new problem. There is documentation that the edema has resolved, and the pain
has resolved. The documentation does not support the medical necessity of the requested procedure.
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 requested testing have not been met. Therefore, we decided that the Plan
does not have to pre-approve a duplex scan of extremity veins.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pre-approve home health visits.
You asked the Plan to pre-approve home health visits. You say that the services are necessary. The Plan denied
your request. The Plan says based on the documentation provided, coverage criteria has not been met.
The Plan must follow Medicare rules. The rules say that home health care services may be covered if it is
medically necessary for the enrollee to receive skilled nursing or therapy. A doctor must certify the need for
home health care services.
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 home health visits. Our reviewer says
that the services are not medically necessary. Our physician reviewer found the records do not show that skilled
nursing services are required to effectively provide treatment, care, and/or services in order to improve the
enrollee's condition, or to establish/perform a maintenance program to maintain the enrollee's condition and/or
prevent deterioration. The enrollee's wound care is not complex. There is no evidence of other skilled nursing
need. The enrollee has been educated in disease management. Ongoing skilled services are not medically
necessary. The documentation does not support that the enrollee is homebound as it is not clear that it is a
significant and taxing effort to leave the home. Without skilled nursing or skilled therapy needs and without
being homebound home health aide services are not medically necessary. The enrollee does not meet the
criteria for ongoing skilled home care services.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of home health visits have not been met. Therefore, we decided that the Plan does
not have to pre-approve home health visits.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for chiropractic services provided on January 9, 2020.
You asked the Plan to pay for services not related to manual manipulation of the spine. You say that this
service should be covered by the Plan. The Plan denied your request. The Plan says the services provided were
not related to manual manipulation and are not covered by the Plan or by Medicare.
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. Therefore, we decided that the Plan does not have to pay for chiropractic
services provided on January 9, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for clonidine hydrochloride injections (J0735) and morphine
sulphate injections (J2274) provided on December 18, 2019.
You asked the Plan to pay for the injections. You say that you would like reconsideration based on the records
submitted. The Plan denied your request. The Plan says the documentation submitted does not support the
number of units billed.
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 asked our coder 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 injections. Our reviewer says that CPT code J0735x4
does not meet criteria for billing or reimbursement consideration. The medical records indicate that this drug
was compounded, therefore HCPCS code J9735 would not be be appropriate code to represent this service. Our
coder found CPT code J2274x50 does not meet criteria for billing or reimbursement consideration. The
medical records indicate that this drug was compounded, therefore HCPCS code J2274 would not be be
appropriate code to represent this service.
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of the injections have not been met. Therefore, we decided that the Plan does not
have to pay for clonidine hydrochloride injections (J0735) and morphine sulphate injections (J2274) provided
on December 18, 2019.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an electrocardiograph (93000) provided
December 26, 2019.
You asked the Plan to waive the copayment for the electrocardiograph. You say that the copayment should be
included in the office visit. The Plan denied your request. The Plan says the service provided was a separate
service from the office visit, so there is a different copayment.
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
copayment for Diagnostic Tests.
You have been asked to pay an $18.17 copayment for the electrocardiograph. The allowable amount is less
than the $20 copayment stipulated in the Evidence of Coverage. The electrocardiograph falls within the
Diagnostic Tests 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
electrocardiograph (93000) provided December 26, 2019.
Appeal type: Surgery
Decision: Favorable

We decided that the Plan has to pre-approve Theraskin (Q4121).
You asked the Plan to pre-approve Theraskin. You say that the services are necessary. The Plan denied your
request. The Plan says that medical necessity has not been established. Therefore, coverage criteria has not
been met.
The Plan must follow Medicare rules. Medicare rules say that if there are no specific coverage rules for an item
or service, then that item or service will be covered when it is 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 Theraskin. Our reviewer says that the
requested services are considered medically reasonable and necessary in this case. Our physician reviewer
found the enrollee has a persistent wound which has been present for over 8 months, despite extensive
appropriate treatment, including 2 surgical procedures. TheraSkin is a bioactive human skin allograft which has
been associated with higher healing rates of lower extremity wounds, including surgical wounds, than standard
of care alone.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of Theraskin have been met. Therefore, we decided that the Plan has to preapprove
Theraskin (Q4121).
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.