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

 
We decided that the Plan does not have to preapprove a pneumatic compression device (E0652). 
 
You asked the Plan to preapprove a pneumatic compression device. You say that the enrollee requires the 
device. The Plan denied your request. The Plan says the documentation did not support the 4-week trial using 
the basic pump that Medicare requires. 
 
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 preapprove a pneumatic compression device 
(E0652).
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a chest x-ray (71045) provided December 29, 2019. 
 
You asked the Plan to pay for the chest x-ray. You say that the services were medically necessary. The Plan 
denied your request. The Plan says Original Medicare is liable for payment for these services. 
 
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 a chest x-ray (71045) provided December 29, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve core buildup (D2950). 
 
You asked the Plan to pre-approve the core buildup (D2950). You say that this should be based on medical 
necessity. The Plan denied your request. The Plan says the service is not a covered benefit. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plan's coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve core 
buildup (D2950).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an outpatient visit provided on February 4, 2020 by an out of 
network (OON) provider. 
 
You asked the Plan to pay for an outpatient visit. 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. 
 
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 an outpatient visit provided on February 4, 2020 
by an out of network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a powered mobility device (PMD) (K0011). 
 
You asked the Plan to pre-approve the powered mobility device. You say that the PMD is medically necessary. 
The Plan denied your request. The Plan says the records do not include an evaluation to determine if the PMD 
is safe and appropriate for the enrollee. 
 
The Plan must follow Medicare rules. Medicare rules say that for a power mobility device to be approved by 
Medicare, an assessment by a licensed physical therapist is required.  
 
We looked at the file and Medicare rules. There is no evaluation included in the records by a licensed physical 
therapist or otherwise to determine if the power wheelchair is medically appropriate and can be used safely by 
the enrollee. The plan notes such an evaluation was authorized, but there is no record of it being performed. 
Based on this information, we decided that Medicare rules for coverage of the powered mobility device have 
not been met. Therefore, we decided that the Plan does not have to pre-approve a powered mobility device 
(PMD) (K0011).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the CardioMEMS device. 
 
You asked the Plan to pre-approve the CardioMEMS device. You say that this device will help you to better 
monitor the enrollee's condition and symptoms to reduce repeat heart failure hospitalizations and even death. 
The Plan denied your request. The Plan says this device is considered experimental and investigational. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the CardioMEMS device have not been met. Therefore, we decided that the Plan does not have to 
pre-approve the CardioMEMS device.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services (81291, 81479) rendered by the out of 
network (OON) provider on February 28, 2020. 
 
You asked the Plan to pay for these services. You say that you are requesting a reconsideration of the Plan's 
denial for payment. The Plan denied your request. The Plan says the services were provided by an out of 
network provider, without prior authorization. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The provider in this case is not a network provider with the Plan. The Plan has network providers available 
who can provide the services at issue in this appeal. The Plan did not pre-approve the services at issue. We 
found no exception that would require the Plan to pay for these services. Therefore, we decided that the Plan 
does not have to pay for the laboratory services (81291, 81479) rendered by the out of network (OON) provider 
on February 28, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for assembly and operation of pump with oxygenator or heat 
exchanger (with or without ECG and/or pressure monitoring); each hour (99190) provided to the enrollee on 
April 10, 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 this claim cannot be paid separately based on Medicare guidelines for inpatient services. 
The plan must follow Medicare rules. Medicare rules say that CMS does not pay any provider or supplier other 
than the facility or hospital for services furnished to a beneficiary. The facility or hospital must furnish all 
necessary covered services to the beneficiary either directly or under arrangements made with outside 
providers. This equipment was used during and after a surgical procedure by the facility. This equipment did 
not go home with the enrollee. Payment for this service would have been included under the facility claim. 
Payment to you for this service is the responsibility of the facility or hospital. Therefore, we decided that the 
Plan does not have to pay for assembly and operation of pump with oxygenator or heat exchanger (with or 
without ECG and/or pressure monitoring); each hour (99190) provided to the enrollee on April 10, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve foot orthotics (L3000). 
 
You asked the Plan to pre-approve foot orthotics. You say that the foot orthotics are medically necessary. The 
Plan denied your request. The Plan says this item is not a covered benefit. 
 
Medicare rules state that supportive devices for the feet (such as orthotics) are only covered for patients with 
diabetic foot disease or for patients who wear a leg brace. The Plan follows these same rules.   
 
Records show that you do not suffer from diabetic foot disease and you do not wear a leg brace. Although 
orthotics may be appropriate for you, neither Medicare nor the Plan provides coverage of orthotics for your 
condition. Therefore, we decided that the Plan does not have to pre-approve foot orthotics (L3000).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for 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 (S9328) provided to the enrollee from 
November 21, 2019 through February 5, 2020. 
 
You asked the Plan to pay for the service. You say that you are appealing for reconsideration of the denied 
charges. 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 service have not been met. The ?S? codes (temporary codes) 
are used to report drugs, services and supplies for which there are no national codes. These codes are primarily 
used by private insurers for claim processing, policies or programs. These codes are not payable by Original 
Medicare (OM). Therefore, we decided that the Plan does not have to pay for 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 (S9328) 
provided to the enrollee from November 21, 2019 through February 5, 2020.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for radiology services (CPT 78815) provided to the enrollee on 
January 27, 2020. 
 
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. 
The Plan says the service was billed incorrectly with an inappropriate diagnosis. 
 
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 78815 is "Tumor imaging, positron emission tomography 
(PET) with concurrently acquired computed tomography (CT) for attenuation correction and anatomical 
localization." 
 
We find that CPT code 78815 is not supported in the medical record. Specifically, C81.90 - Hodgkin 
lymphoma, unspecified, unspecified site" is not an appropriate diagnosis for this CPT code. 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 radiology services (CPT 78815) provided to the enrollee on 
January 27, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a new patient eye exam (92002) to be rendered by an 
out of network (OON) provider. 
 
You asked the Plan to pre-approve this service. You say that you are requesting a reconsideration of the Plan's 
denial. The Plan denied your request. The Plan says an in-network provider is available to render this service. 
 
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 service at issue in this appeal. We found no exception that would require the 
Plan to pre-approve this service. Therefore, we decided that the Plan does not have to pre-approve a new 
patient eye exam (92002) to be rendered by an out of network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the semi-electric hospital bed (E0260). 
 
You asked the Plan to pre-approve the semi-electric hospital bed. You say that your bedroom is on the second 
floor of your home and because of recent surgery you cannot tolerate the stairs and needs the hospital bed for 
the first floor of your home. The Plan denied your request. The Plan says the enrollee does not meet the 
Medicare criteria for coverage for a semi-electric hospital bed. 
 
The Plan must follow Medicare rules. The rules say that a semi-electric hospital bed may be considered 
medically necessary when the patient: 
 
1. Has a medical condition which requires positioning of the body in ways not feasible with an ordinary bed; or 
 
2. Requires attachments which can only be attached to a hospital bed; AND 
 
3. Requires frequent changes in body position and/or has an immediate need for a change in body position. 
 
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 semi-electric hospital bed. Our 
reviewer says that the requested items/services are not considered medically reasonable and necessary in this 
case. Our physician reviewer found the enrollee's condition does not require positioning of the body in ways 
not feasible in an ordinary bed. The enrollee does not require frequent or immediate changes in body position 
or special attachments that cannot be fixed and used on an ordinary bed. A semi-electric hospital bed is not 
medically necessary for this enrollee. 
 
 
 
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 semi-electric hospital bed have not been met. Therefore, we decided that the 
Plan does not have to pre-approve the semi-electric hospital bed (E0260).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for assembly and operation of pump with oxygenator or heat 
exchanger (with or without ECG and/or pressure monitoring); each hour (99190) provided to the enrollee on 
April 15, 2020. 
 
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 this claim cannot be paid separately based on Medicare guidelines for inpatient services. 
The plan must follow Medicare rules. Medicare rules say that CMS does not pay any provider or supplier other 
than the facility or hospital for services furnished to a beneficiary. The facility or hospital must furnish all 
necessary covered services to the beneficiary either directly or under arrangements made with outside 
providers. This equipment was used during and after a surgical procedure by the facility. This equipment did 
not go home with the enrollee. Payment for this service would have been included under the facility claim. 
Payment to you for this service is the responsibility of the facility or hospital. Therefore, we decided that the 
Plan does not have to pay for assembly and operation of pump with oxygenator or heat exchanger (with or 
without ECG and/or pressure monitoring); each hour (99190) provided to the enrollee on April 15, 2020.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay more towards the cost of a reduction mammaplasty and 
lipectomy services provided on January 29, 2020. 
 
You asked the Plan to pay more towards the cost of the reduction mammaplasty and lipectomy services. You 
say that you paid $10,000 upfront for the services, which were pre-authorized by the Plan. The Plan denied 
your request. The Plan says the allowed amount was paid for the procedures and balance billing is not paid by 
either the Plan or the enrollee. 
 
The Plan must follow Medicare rules. Medicare rules say that noncontract providers must accept the amount 
they would receive under Original Medicare as payment in full. Noncompliance is subject to federal penalties. 
 
In this case, the plan has confirmed that the provider has been paid up to the limiting charge for this reduction 
mammaplasty. The payment for the suction assisted lipectomy is bundled into the payment made for the 
primary mammaplasty procedure. Neither you nor the plan are responsible for paying more than this amount. 
Therefore, we decided that the Plan does not have to pay more towards the cost of a reduction mammaplasty 
and lipectomy services provided on January 29, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the drug testing services provided on July 11, 2019.

You asked the Plan to pay for the services. The Plan denied your request. The Plan says the billed code cannot be verified.

The Plan must follow Medicare rules. Medicare rules say that the physician must clearly document, in the medical record, his or her intent that the test be performed. 

We looked at the file and Medicare rules. The records provided do not contain a valid physician order or lab requisition stating exactly which testing was to be performed. 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 the drug testing services provided on July 11, 2019.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for Comprehensive Genomic Profile (CGP) testing provided to 
the enrollee on March 26, 2020. 
 
You asked the Plan to pay for the testing. You say that this should be paid for. The Plan denied your request. 
The Plan says this test should be covered with CPT 81479. 
 
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 find that the various denied CPT codes are not supported in the medical record. Specifically, the testing at 
issue in this case should be reported with CPT 81479. Based on this information, we decided that Medicare 
rules for coverage of the testing have not been met. Therefore, we decided that the Plan does not have to pay 
for Comprehensive Genomic Profile (CGP) testing provided to the enrollee on March 26, 2020.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the lab services you received on January 
22, 2020. 
 
You asked the Plan to waive the copayment. The Plan denied your request. The Plan says you are responsible 
for the cost share. 
 
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 lab services. 
 
Review of the file shows that you were provided lab services on January 22, 2020. Per your contract with the 
Plan, there is a $20 copayment for lab services. However, the allowed amount for these services was $12.05. 
You have been asked to pay the lesser amount of $12.05. 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 lab services you received on January 22, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to reduce the cost for the oral device/appliance provided on November 
20, 2019. 
 
You asked the Plan to reduce the cost for the oral device/appliance. You say that this service was rendered by 
an in-network provider. The Plan denied your request. The Plan says the out-of-network cost applied correctly. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information. Your 
contract with the Plan says that your deductible is $500. This is the amount you have to pay out-of-pocket 
before we will pay our share for your covered medical services. Until you have paid the deductible amount, 
you must pay the full cost of your covered services. Your contract with the Plan also says that you must pay 
20% coinsurance for durable medical equipment from an out-of-network provider. 
 
The item or service you asked the Plan to reduce the cost for falls within the "Durable medical equipment 
(DME) and related supplies" benefit category The Plan has followed Medicare rules by clearly disclosing in the 
contract that your $500 deductible applies to durable medical equipment. This cost sharing is a contractual 
obligation that had not been met at the time the oral device/appliance was received on November 20, 2019. 
Therefore, $500 has been applied to meet your deductible. 
  
 
Since your $500 deductible was met, you have also been asked to pay $297.60, which is 20% of the allowed 
amount for the oral device/appliance. The allowed amount is $1,488 (20% x $1,488 = $297.60). The total 
amount you owe is $797.60 ($500 + $297.60 = $797.60). 
 
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 reduce the cost for the oral device/appliance provided on November 20, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the office visit provided on March 4, 2020 by an out of 
network (OON) provider. 
 
You asked the Plan to pay for these OON services. You say that you would like the plan to reconsider their 
denial. The Plan denied your request. The Plan says the services rendered are not a covered benefit. 
 
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 the office visit provided on March 4, 2020 by an 
out of network (OON) provider.