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

 
We decided that the Plan does not have to pay for the automated external defibrillator rental (K0606) provided 
on June 27, 2020. 
 
You asked the Plan to pay for this item. You say that you are requesting a reconsideration of the Plan's denial 
for payment. The Plan denied your request. The Plan says the item provided is not covered under the 
contractual policy or by Medicare as the enrollee was in an inpatient status at the time of service. 
 
The Plan must follow Medicare rules. Medicare rules say that the DMEPOS benefit is meant only for items a 
beneficiary is using in his or her home. For a beneficiary in a Part A inpatient stay, an institutional provider is 
not defined as a beneficiary?s home for DMEPOS, and so Medicare does not make separate payment for 
DMEPOS when a beneficiary is in the institution. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of this item have not been met. Specifically, the record shows that the enrollee was an inpatient 
during the date of service at issue. Medicare does not make separate payment for DMEPOS when a beneficiary 
is in an institution. The institution is expected to provide all medically necessary DMEPOS during a 
beneficiary's covered Part A stay. Therefore, we decided that the Plan does not have to pay for the automated 
external defibrillator rental (K0606) provided on June 27, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a periodic oral evaluation (D0120) and a prophylactic dental 
cleaning (D1110) performed by an out of network provider. 
 
You asked the Plan to pay for a periodic oral evaluation and a prophylactic dental cleaning. You say that you 
were told the provider was an in-network provider. The Plan denied your request. The Plan says rules for 
payment have not been met. 
 
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 
covered under this benefit when received from an out of network provider. Therefore, we decided that the Plan 
does not have to pay for a periodic oral evaluation (D0120) and a prophylactic dental cleaning (D1110) 
performed by an out of network provider.  
 
Your complaint about receiving erroneous or misleading information about your network of providers from a 
representative of the Plan 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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the co payment for a specialist visit provided. 
 
You asked the Plan to waive the co payment for a specialist visit. You say that this was a follow-up visit and 
you should not be responsible for 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 
co payments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $45 
co payment for each specialist visit.  
 
You have been asked to pay a $45 co payment for a specialist visit. A specialist visit falls within the 
physician/practitioner services, including doctor's office visits benefit category. This means that you have been 
asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual 
obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have 
to waive the co payment for a specialist visit provided.
Appeal type: Outpatient Therapies
Decision: Favorable

 
We decided that the Plan has to pre-approve 10 additional occupational therapy (OT) visits (97168). 
 
You asked the Plan to pre-approve the additional OT visits. You say that your quality of life has lessened since you can't 
use your hand. You need the intense therapy that is being denied. Since the OT has stopped 3 weeks again any progress 
has regressed. The Plan denied your request. The Plan says that the additional OT visits are not medically necessary and 
the enrollee did not meet the Medicare criteria for coverage. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for medically necessary outpatient 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 the additional OT visits. Our reviewer says that the enrollee 
meets the Medicare criteria for the additional occupational therapy visits. Our physician reviewer found The plan 
approved 12 OT visits, beginning on 8/12/20. The OT visit on 9/29/20 is noted to be visit 10 out of 10. It is documented 
that the enrollee was no longer able to complete her previous exercise program and has suffered a significant decline in 
function. OT is generally accepted as a specific and effective therapy for spastic hemiparesis. The documentation 
supports that the unique skills of a professional therapist are required to safely and effectively provide treatment in this 
case.    The documentation does not support that the requested services are part of a maintenance 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 the additional OT visits have been met. Therefore, we decided that the Plan has to pre-approve 10 
additional occupational therapy (OT) visits (97168).  
 
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again if we 
believe there was a mistake or if there is new information to review. The Plan has to show us the mistake and/or send us 
the new information. This does not happen often. If we decide to open the case again, we will send you a letter.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Myobloc for the enrollee. 
 
You asked the Plan to pre-approve the drug. You say that this is medically necessary. The Plan denied your 
request. The Plan says use of this drug for an off-label diagnosis is not supported. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for a drug or biological only if it is safe 
and effective and otherwise reasonable and 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 the drug. Our reviewer says that the 
requested drug is not medically reasonable or necessary. Our physician reviewer found the requested 
medication was noted for the treatment of cramp and spasm related to a cerebrovascular. This is not a diagnosis 
supported the regulations and compendia. Medical necessity cannot be determined. 
 
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 drug have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Myobloc for the enrollee.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the outpatient surgery services provided. 
 
You asked the Plan to pay for the surgery services. You say that this surgery did not require authorization as it 
was needed on an emergency basis. The Plan denied your request. The Plan says this surgery was billed with 
two inappropriate codes for this patient.   
 
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 code S1015 is not an appropriate or covered code for Medicare purposes. S codes are only used 
for commercial insurance and should not be used for Medicare enrollees.  In addition, code J8499 is explicitly a 
non-covered item/service per Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the surgery services have not been met. Therefore, we decided that the Plan does not have to pay 
for the outpatient surgery services provided as they have been billed.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the medical services provided on July 17, 2020 by an out of 
network (OON) provider. 
 
You asked the Plan to pay for the medical services. You say that you don't believe that authorization was 
required. The Plan denied your request. The Plan says unauthorized, non-plan care is not 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 provider in this case is not a network provider with the Plan. 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 the medical services provided on July 17, 2020 by an OON provider.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for intraoperative neuromonitoring services (HCPCS G0453) 
provided to the enrollee on August 29, 2019. 
 
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 payment for this service would be included in the facility PPS payment. 
 
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 HCPCS code G0453 is "Continuous intraoperative 
neurophysiology monitoring, from outside the operating room (remote or nearby), per patient, (attention 
directed exclusively to one patient) each 15 minutes (list in addition to primary procedure)." 
 
We asked our coding 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 services. Our reviewer says that the 
services at issue in this case were not supported by the medical records. Our coding reviewer found the 
documentation submitted was reviewed, and does not meet the criteria. Per CMS, Code of Federal Regulations 
(CFR) 412.50(b) CMS does not pay any provider or supplier other than the hospital for services furnished to a 
beneficiary who is an inpatient, except for the services described in paragraphs (a)(1) through (a)(6) of this 
section, and, Code of Federal Regulations (CFR) 412.50 (c) The hospital must furnish all necessary covered 
services to the beneficiary either directly or under arrangements (as defined in 409.3 of this chapter). Therefore, 
HCPCS G0453, would not be reimbursed separately through Medicare. 
 
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 services have not been met. Therefore, we decided that the Plan does not 
have to pay for intraoperative neuromonitoring services (HCPCS G0453) provided to the enrollee on August 29, 2019.
Appeal type: Inpatient Hospital
Decision: Favorable

 
We decided that the Plan has to pre-approve continued inpatient services. 
 
You asked the Plan to pre-approve continued inpatient services. You say that you would like the plan to 
reconsider their denial. The Plan denied your request. The Plan says that the requested services are not 
medically necessary. 
 
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 inpatient services. Our reviewer says 
that the requested items/services are considered medically reasonable and necessary in this case. Our physician 
reviewer found the enrollee still had Shortness of breath, exact etiology not clear. The enrollee's breathing was 
described as stable. He complained of generalized weakness. Vital signs were noted and acceptable. Patient 
was afebrile. The documentation supports that the enrollee has a diagnosis, condition, and/or symptoms that 
met the Medicare criteria for coverage of inpatient services. The inpatient services are considered the standard 
of care for the treatment of this enrollee's condition. 
 
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 services have been met. Therefore, we decided that the Plan has to pre-
approve continued inpatient services.  
 
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again 
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake 
and/or send us the new information. This does not happen often. If we decide to open the case again, we will 
send you a letter.
Appeal type: Imaging
Decision: Favorable

We decided that the Plan has to pay for the radiology services provided on July 17, 2020. 
 
You asked the Plan to pay for the radiology services. You say that you would like the Plan to reconsider their 
denial of payment. The Plan denied your request. The Plan says that the services are not covered. 
 
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and 
diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or 
payment. 
 
The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their 
decision to deny your request. The Plan has not provided us with any valid rationale to support the denial of 
payment for these services. Therefore, we decided that the Plan has to pay for the radiology services provided 
on July 17, 2020.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the colonoscopy provided on September 2,
2020.
You asked the Plan to waive the copayment for the colonoscopy. You say that it is your understanding that this
procedure is covered. You say that it was not explained that the colonoscopy was not free if you had a positive
Cologuard test. The Plan denied your request. The Plan says the copayment 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 $300 for
each Medicare-covered outpatient admission to an outpatient hospital facility. Outpatient surgery includes any
procedure performed in an ambulatory surgical center or hospital outpatient department, including diagnostic
tests such as colonoscopies, endoscopies and minor procedures.
You have been asked to pay a $300 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 records show that polyps were removed during the colonoscopy which is
considered a surgical procedure.
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 September 2, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the pneumatic compressor (E0651) and a full leg segmental 
pneumatic appliance (E0667) provided on August 20, 2020. 
 
You asked the Plan to pay for the pneumatic compressor and a full leg segmental pneumatic appliance. You say 
that the items are necessary. The Plan denied your request. The Plan says based on the documentation 
provided, coverage criteria has not been met. 
 
The Plan follows Medicare rules. Medicare rules say that a four-week trial of conservative therapy 
demonstrating failed response to treatment with and E0650 or E0651 is required. 
 
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 pneumatic compressor and a full leg 
segmental pneumatic appliance. Our reviewer says that the items are not medically necessary. Our physician 
reviewer found based on the medical records provided there is no documentation that the enrollee meets the 
coverage criteria for the pneumatic compression device. The provided records do not document trial and failure 
of four weeks of conservative therapy. 
 
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 pneumatic compressor and a full leg segmental pneumatic appliance have 
not been met. Therefore, we decided that the Plan does not have to pay for the pneumatic compressor (E0651) 
and a full leg segmental pneumatic appliance (E0667) provided on August 20, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Life Alert System (E1399). 
 
You asked the Plan to pre-approve this item. You say that a Life Alert System is medically necessary. The Plan 
denied your request. The Plan says the requested device does not meet Medicare criteria for coverage. 
 
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a 
medical purpose.   
 
The item at issue in this appeal does not serve a purpose that is primarily medical in nature, as it does not 
directly treat a medical condition. Therefore, we decided that the Plan does not have to pre-approve a Life Alert 
System (E1399).
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the cystoscopy provided on August 14, 2020. 
 
You asked the Plan to waive the copayment for the cystoscopy. You say that you previously had this procedure 
once a month and now once a year. You say that you are concerned the procedure won't be paid for. The Plan 
denied your request. The Plan says the copayment 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 a $250 
copayment for Medicare-covered outpatient surgery in an ambulatory surgical center or hospital outpatient facility.  
 
You have been asked to pay a $250 copayment for the cystoscopy. The cystoscopy falls within the "Outpatient 
surgery, including services provided at hospital outpatient facilities and ambulatory surgical centers" 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 the cystoscopy provided on August 14, 2020.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pay forthe home health services provided to the enrollee from July 1, 2020, to July 30, 2020.You asked the Plan to pay forhome health services. You say that the services provided were medically necessary and billed correctly.The Plan denied your request. The Plan says the type of bill code is invalid for the services provided.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 services were billed with an invalid type of bill code. Therefore, we decided that the Plan does not have to pay forthe home health services provided to the enrollee from July 1, 2020, to July 30, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a new prosthetic leg. 
 
You asked the Plan to pre-approve a new prosthetic leg. You say that you would like the plan to reconsider 
their denial. The Plan denied your request. The Plan says the requested item is not medically necessary. 
 
The Plan follows Medicare rules. Medicare rules say that new prosthetic legs are only covered for certain 
indications. 
 
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 a new prosthetic leg. Our reviewer says 
that the documentation does not support that the requested item is medically reasonable or necessary. Our 
physician reviewer found the documentation does not support that you have a diagnosis, condition, and/or 
symptoms that meet the Medicare criteria for coverage of a new prosthesis. Your current prosthesis was 
approved on December 11, 2019 and records do not document a physiologic change requiring a new prosthesis 
or damage or loss of the current prosthesis. Therefore, you do not meet criteria for the requested item. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of a new prosthetic leg have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a new prosthetic leg.