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

We decided that the Plan does not have to pre-approve a recliner chair (E1399). 
 
You asked the Plan to pre-approve a recliner chair. You say that you are requesting a reconsideration of the 
Plan's denial. The Plan denied your request. The Plan says that the recliner chair does not meet Medicare 
criteria for coverage.  
 
The Plan must follow Medicare rules. The rules say that Medicare will pay for durable medical equipment that 
is mainly used to serve a medical purpose. 
 
We looked at the case file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of a recliner chair have not been met. Specifically, a recliner chair is not durable medical equipment 
that is mainly used to serve a medical purpose. Therefore, we decided that the Plan does not have to pre-
approve a recliner chair (E1399).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the services (CPT 99152) provided on March 24, 2020. 
 
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 providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
In this case, the CPT Code Manual definition of code 99152 is "Moderate sedation services provided by the 
same physician or other qualified health care professional performing the diagnostic or therapeutic service that 
the sedation supports, requiring the presence of an independent trained observer to assist in the monitoring of 
the patient's level of consciousness and physiological status; initial 15 minutes of intraservice time, patient age 
5 years or older." 
 
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 use 
of CPT code 99152 is not supported by the records provided. Our coding reviewer found that the operative 
report does not document an independent observer to assist in the monitoring of the patient's level of 
consciousness and physiological status during procedure. 
 
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 the services (CPT 99152) provided on March 24, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for oxygen equipment provided to the enrollee from April 24, 
2020, to May 23, 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 the claim records show from December 24, 2019, to January 23, 2020 was the 36th 
continuous month billed for the E1390 Oxygen concentrator. No further payment for oxygen equipment will be 
made during the 5-year RUL after rental payments are made for 36 months of continuous use. Medicare billing 
criteria were not met. The Plan states a corrected claim would be reviewed if submitted.  
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate codes. Medicare rules say there is a 36-month capped rental 
period for oxygen equipment. In this case, the claim submitted cannot be paid due to the capped rental rules 
and previously submitted claims. Medicare billing criteria are not met. Therefore, we decided that the Plan does 
not have to pay for oxygen equipment provided to the enrollee from April 24, 2020, to May 23, 2020.
Appeal type: Lab
Decision: Partially Favorable

We decided that the Plan has to pay for the blood sample collection fee. We decided that the Plan does not have 
to pay for the vitamin D testing.  
 
You asked the Plan to pay for the blood sample collection fee. You say that all billed services should be paid. 
The Plan says that these services were denied due to being done for screening purposes. 
 
We decided that the Plan has to pay for the blood sample collection fee.  
 
The Plan follows Medicare rules. Medicare rules say that plans must make diligent efforts to submit 
documentation to supports its denials. The rules also say that specimen collection fee is allowed in 
circumstances such as drawing a blood sample through venipuncture. 
 
In this case, there is no argument made to justify denial of payment of this collection fee. The documentation 
provided does not include evidence to disprove that this sample was taken from either a nursing home or home 
health patient. Therefore, we decided that the Plan has to pay for the blood sample collection fee.  
 
We also decided that the Plan does not have to pay for the vitamin D testing. 
 
The Plan follows Medicare rules. Medicare rules say that screening tests, except for the above referenced 
services, are not covered. 
 
In this case, the documentation does not include any signs or symptoms for which the vitamin D testing was 
ordered. Neither of the billed diagnosis codes justify this testing. As such, this is considered an excluded 
screening test. Therefore, we decided that the Plan does not have to pay for the vitamin D testing. 
 
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 compression stockings identified with code A6549. 
 
You asked the Plan to pre-approve the compression stockings. You say that your doctor prescribed these for 
varicose veins. The Plan denied your request. The Plan says compression stockings are not a covered item. 
 
The Plan must follow Medicare rules. The rules say that compression stockings described by code A6549 are 
noncovered because they do not meet the statutory definition of a surgical dressing.  
 
Although this item may be appropriate, it does not fall into a covered benefit category and cannot be paid for 
by Medicare or the Plan. Therefore, we decided that the Plan does not have to pre-approve compression 
stockings identified with code A6549.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for chiropractic services provided on June 10, 2019. 
 
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 the providers office confirmed you did not have a referral or prior 
authorization for this service. 
 
Medicare rules say that plans can require enrollees to get care from network providers and require prior 
authorization.  The contract with the Plan says that chiropractic care requires a referral and prior authorization.  
The Plan did not pre-approve these services. 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 chiropractic services provided on 
June 10, 2019.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pre-approve home health services for the enrollee. 
 
You asked the Plan to pre-approve the services. You say that this is medically necessary. The Plan denied your 
request. The Plan says the care plan was not received from the doctor's office. 
 
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 the services. Our reviewer says that the 
requested services are not medically reasonable or necessary. Our physician reviewer found no medical records 
have been submitted for review. Therefore, there is no evidence to support that the requested service is 
medically necessary and reasonable. 
 
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 home health services for the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided on February 10, 2020 by an 
out of network (OON) provider. 
 
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says the services were rendered 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 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 medical services provided on February 10, 
2020 by an out of network (OON) provider.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a computed tomography (CT) scan of the thorax 
(71250). 
 
You asked the Plan to pre-approve this service. You say that a CT scan of the thorax is medically necessary for 
the enrollee. The Plan denied your request. The Plan says a CT scan of the thorax is not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that CT scans are covered only when they are 
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 this service. Our reviewer says that a 
CT scan of the thorax is not medically necessary. Our physician reviewer found that the enrollee has 
complaints of chest and back pain. The electrocardiogram (EKG) from October 9, 2020, demonstrated inferior 
ST/T wave changes possibly due to myocardial ischemia. A CT Scan of the chest, without contrast has been 
requested. A CT scan of the chest is indicated to diagnose muscle and bone disorders, such as bone tumors and 
fractures. Pinpoint the location of a tumor, infection or blood clot. Guide procedures such as surgery, biopsy 
and radiation therapy detect and monitor diseases and conditions such as cancer, heart disease, lung nodules 
and liver masses. In this case there was no chest x-ray provided for review. There is no specific clinical 
rationale for the requested CT Scan of the chest. The review has determined that the requested CT scan is not 
medically necessary or reasonable. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of this service have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a computed tomography (CT) scan of the thorax (71250).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for the hyaluronan injections and 
methylprednisolone acetate injection provided on March 5, 2020. 
 
You asked the Plan to waive the coinsurance for the hyaluronan injections and methylprednisolone acetate 
injection. You say that you were told the medication was covered by insurance. You say that if you knew it 
wasn't covered you wouldn't have had the injections. 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 each Medicare-covered Part B drug.  
 
You have been asked to pay a total of $443.21 for the hyaluronan injections and methylprednisolone acetate 
injection.  
 
Service Allowed                                   Amount       Coinsurance      Member Liability 
Hyaluronan Injections                           $2,209.20    20%                 $441.84 
Methylprednisolone Acetate Injection     $6.88          20%                 $1.37 
TOTAL:   $443.21 
 
The hyaluronan injections and methylprednisolone acetate injection 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 hyaluronan 
injections and methylprednisolone acetate injection provided on March 5, 2020.  
 
Your complaint about being misinformed 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: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the maxillary partial denture and mandibular partial denture 
provided on June 5, 2020. 
 
You asked the Plan to pay for the maxillary partial denture and mandibular partial denture. You say that you 
agreed to pay $257 per month for 18 months, with no interest applied if paid on time. You also say that to date, 
you have fulfilled your commitment of these payments, and do not believe you should be held responsible for 
the additional charge of $1,730. The Plan denied your request. The Plan says these services 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. 
 
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. Your plan only provides coverage for complete dentures. Partial 
dentures are not listed as a covered service. Therefore, we decided that the Plan does not have to pay for the 
maxillary partial denture and mandibular partial denture provided on June 5, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve diabetic shoes and inserts. 
 
You asked the Plan to pre-approve diabetic shoes and inserts. You say that these shoes and inserts 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 diabetic shoes and inserts.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for complete upper denture (D5110) Complete lower denture 
(D5120) provided July 23, 2020 
 
You asked the Plan to pay for the dentures. You say that your dentures had broken and the Plan had told you to 
get another pair of dentures. You do not have the money to pay for dentures. The Plan denied your request. The 
Plan says this request exceeds the allowed benefit maximum of once every 5 years. 
 
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. Per page 85 of the health plan 
contract, 1 complete upper and/or 1 complete lower denture is allowed once every 5 years. The records show 
that you received this service on July 9, 2019. 
 
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 pay for complete 
upper denture (D5110) Complete lower denture (D5120) provided July 23, 2020
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pay for the home health services provided from April 19, 2020, to 
April 20, 2020. 
 
You asked the Plan to pay for the home health services. You say that the Plan should pay this claim. The Plan 
denied your request. The Plan says the claim was billed with an invalid HIPPS code for the services billed. 
 
The Plan must follow Medicare rules. Medicare 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 provider 
is a non-contract provider for the enrollee's health plan and a valid RAP claim was not submitted prior to the 
final claim for processing. Therefore, we decided that the Plan does not have to pay for the home health 
services provided from April 19, 2020, to April 20, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for a Medicare Part B drug injection and does 
not have to waive the copayment for the administration provided on January 30, 2020. 
 
You asked the Plan to waive the coinsurance for a Medicare Part B drug injection and to waive the copayment 
for the administration. You say that you disagree with how the claim was billed because it resulted in the Plan 
not covering 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 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay 20% 
coinsurance for Medicare Part B prescription drugs. Your contract with the Plan also clearly says that you must 
pay a $295 copayment for outpatient surgery and other medical services provided at hospital outpatient 
facilities and ambulatory surgical centers. 
 
You received a Medicare Part B drug injection on January 30, 2020. The allowed amount is $1,996.05 and 20% 
of that is $399.21. You are also responsible to pay the total allowed amount of $241.54, which is less than the 
copayment amount, for the administration. The total amount you owe is: $640.76.   
 
You have been asked to pay the total amount of $640.76 for a Medicare Part B drug injection and the 
administration. A Medicare Part B drug injection falls within the Medicare Part B prescription drugs benefit 
category. The administration falls within the outpatient surgery and other medical 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 
coinsurance for a Medicare Part B drug injection and does not have to waive the copayment for the 
administration provided on January 30, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve VenaSeal, endovenous ablation therapy of incompetent 
vein (36482). 
 
You asked the Plan to pre-approve VenaSeal. You say that you believe the denial of the procedure to treat 
varicose veins, should be covered due to medically necessity. The Plan denied your request. The Plan says this 
procedure is considered experimental, investigational or unproven as there is lack of evidence to support this 
procedure over treatment of incompetent veins. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered. The rules also say that experimental and investigational devices are not covered. 
 
We looked at the file, and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of VenaSeal have not been met. Therefore, we decided that the Plan does not have to pre-approve 
VenaSeal, endovenous ablation therapy of incompetent vein (36482).
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve home health physical therapy and occupational therapy 
visits. 
 
You asked the Plan to pre-approve home health care. You say that you are appealing based on medical 
necessity. The Plan denied your request. The Plan says the denial of authorization for home health care is 
correct. 
 
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 care. Our reviewer says 
that the enrollee does not meet the Medicare criteria for the requested home health care. Our physician reviewer 
found based on the medical records provided, there is no documentation that skilled therapy services are 
 
 
required to effectively provide treatment, care, and/or services in order to improve the enrollee's level of 
function, or to establish/perform a maintenance program to maintain the enrollee's level of function and/or 
prevent deterioration. The enrollee continues to require minimum to moderate assistance with transfers, total 
dependence for toileting and bathing, and moderate assistance with ambulation with a walker despite treatment 
since April 2020. The enrollee appears to have reached his maximum level of functional recovery.  
 
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 care have not been met. Therefore, we decided that the Plan does 
not have to pre-approve home health physical therapy and occupational therapy visits.