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

 
We decided that the Plan does not have to pay for the electrical stimulator supplies, 2 lead, per month, (e.g., 
TENS, NMES) (A4595) provided September 4, 2022. 
 
You asked the Plan to pay for the electrical stimulator supplies. You say that please review the claim denial for 
accuracy. The claim was billed in accordance with the Plan policy allowable, accepted procedure codes and 
diagnosis codes according to the Plan type. The Plan denied your request. The Plan says evidence of 
misrepresentation. 
 
The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when there are both a 
physician order and proof of delivery.  
 The record does not contain a valid physician order, or relevant medical records which support medical 
necessity for the supplies provided in this case. Specifically, the order date is missing from the submitted 
physician prescription (order). Also, medical records were requested from the provider. The record shows that 
the Plan made several attempts to obtain the necessary documentation without success. Therefore, we decided 
that the Plan does not have to pay for the electrical stimulator supplies, 2 lead, per month, (e.g., TENS, NMES) 
(A4595) provided September 4, 2022.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Prolia. 
 
You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied 
your request. The Plan says the step therapy requirement is not met. 
 
Medicare covers Part B medications when they are reasonable and necessary but allows health plans to 
implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain 
Part B medications.  
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 these services. Our reviewer says that 
the services are not medically necessary. Our physician reviewer found the enrollee as age-related osteoporosis 
without current pathological fracture. She has not tried and failed the Plan's required drug, zoledronic acid. The 
records do not show that the required drug would be contraindicated or less effective; therefore, Prolia is not 
reasonable or medically necessary. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of these services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve Prolia.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for validity testing billed with code 83789 for date(s) of service 
February 9, 2022. 
 
You asked the Plan to pay for code 83789. You say that this service is medically necessary and should be paid. 
The Plan denied your request. The Plan says code 83789 is not separately payable. 
 
The Plan must follow Medicare rules. Medicare rules say that providers performing validity testing on urine 
specimens utilized for drug testing should not separately bill the validity testing. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of code 83789 have not been met. Specifically, we find that the testing described by code 83789 is not 
separately payable. Therefore, we decided that the Plan does not have to pay for validity testing billed with 
code 83789 for date(s) of service February 9, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the genetic testing provided on July 12, 2022, billed with 
multiple individual gene and panel codes. 
 
You asked the Plan to pay for the genetic testing billed. You say that this was medically necessary testing 
which was correctly billed with 21 line items. The Plan denied your request. The Plan says panel testing should 
be billed using one CPT code on the claim. 
 
The Plan must follow Medicare rules. The rules say that if one laboratory procedure evaluates multiple genes 
using a next generation sequencing (NGS) procedure, the laboratory shall report only one unit of service of one 
genomic sequencing procedure, molecular multianalyte assay, multianalyte assay with algorithmic analysis, or 
proprietary laboratory analysis code. 
 
 We looked at the file and Medicare rules. This was an NGS panel that was not billed with a single panel code 
as required. Based on this information, we decided that Medicare rules for coverage of the genetic testing billed 
have not been met. Therefore, we decided that the Plan does not have to pay for the genetic testing provided on 
July 12, 2022, billed with multiple individual gene and panel codes.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve 170 dialysis treatments to be provided by an out-of-
network (OON) provider. 
 
You asked the Plan to pre-approve 170 dialysis treatments to be provided by an OON provider. You say that 
the services are necessary. The Plan denied your request. The Plan says there are in-network providers that are 
able to provide these services. Therefore, coverage criteria have not been met. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pre-approve care from out-of-network providers only in cases involving 
emergencies, out of area urgent care and care that cannot be provided by network providers. 
 
The requested provider in this case is not a network provider with the Plan. The Plan has network providers 
available who can provide the items/services at issue in this appeal. We found no exception that would require 
the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve 
170 dialysis treatments to be provided by an out-of-network (OON) provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services. 
 
You asked the Plan to pre-approve the LTACH services. You say that the services are medically necessary for 
the enrollee to improve their medical needs. The Plan denied your request. The Plan says the enrollee is 
receiving appropriate inpatient acute care and is currently unstable for transfer. 
 
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically 
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the LTACH services. Our reviewer says 
that the requested LTACH care is not considered medically reasonable and necessary in this case. Our 
physician reviewer found the enrollee does not require services at the LTACH that are not already available at 
the current facility. Completion of treatment at the current facility is recommended.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve long term acute care hospital (LTACH) services.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for inpatient hospital services provided on October 22, 2021, to 
November 2, 2021, at the DRG originally billed. 
 You asked the Plan to pay for the inpatient hospital services at the DRG originally billed. You say that the 
services at issue have been billed correctly. The Plan denied your request. The Plan says rules for payment 
have not been met. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report inpatient hospital services with the appropriate DRG, which is based, in part, on the 
reported principal and secondary diagnosis codes.   
 
In this case, you billed the inpatient services provided with principal diagnosis code J15.6, defined as 
Pneumonia due to other Gram-negative bacteria. 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 inpatient hospital services at the DRG originally billed. Our reviewer says that the inpatient hospital 
services at issue do not meet criteria for payment at the DRG originally billed. Our physician reviewer found 
that in this case, although gram-negative pneumonia was documented in the record, the following payer-
specific criteria were not supported: a sputum gram stain, sputum culture or blood culture growing a gram-
negative organism that is a pulmonary pathogen, or a positive urine antigen test for Legionella (which is a 
gram-negative organism). The documentation did not support diagnosis code J15.6.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided the 
medical records do not substantiate the DRG as billed. Therefore, we decided that the Plan does not have to pay 
for inpatient hospital services provided on October 22, 2021, to November 2, 2021, at the DRG originally 
billed.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a medical eye examination (92004) 
provided on April 05, 2021. 
 
You asked the Plan to waive the copayment for a medical eye examination (92004). You say that the provider 
refused to honor your insurance, even when you showed where his name was listed as in-network. The Plan 
denied your request. The Plan says this cost sharing was charged 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 $35 
copayment for Medicare-covered examination to treat an eye condition. 
 
You have been asked to pay a $35 copayment for a medical eye examination (92004). This item/service falls 
within the Medicare-covered examination to treat an eye condition 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 a medical eye examination (92004) provided on April 05, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for disposable underpads, all sizes (A4554) incontinence 
garment, any type, (e.g., brief, diaper), each (A4520) incontinence supply; miscellaneous (A4335) provided 
February 9, 2022. 
 
You asked the Plan to pay for incontinence supplies. You say that please reconsider date of service February 9, 
2022. Physician order is attached for review. The Plan denied your request. The Plan says these items are not 
covered. 
 
The Plan covers all items that Medicare covers. Medicare rules state that incontinence supplies are not covered 
because they are hygienic items that are non-reusable.  
 
While incontinence supplies may be appropriate in this case, neither the Plan nor Medicare offers coverage of 
these items. Therefore, we decided that the Plan does not have to pay for disposable underpads, all sizes 
(A4554) incontinence garment, any type, (e.g., brief, diaper), each (A4520) incontinence supply; miscellaneous 
(A4335) provided February 9, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve spinal cord stimulator trial. 
 
You asked the Plan to pre-approve spinal cord stimulator (SCS) trial. 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 follows Medicare rules. Medicare rules say that no payment may be made for the implantation of 
dorsal column or depth brain stimulators or services and supplies related to such implantation, unless all 
specific criteria are met. 
 
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 SCS trial. Our reviewer says that the services are not medically necessary. Our physician reviewer found the enrollee does not have an evidence 
based indication for a SCS trial and has not had an adequate trial of conservative therapy nor has she had a 
surgical consultation. The procedure is deemed not medically reasonable and necessary. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of SCS trial have not been met. Therefore, we decided that the Plan does not have 
to pre-approve spinal cord stimulator trial.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code S9502 billed for date of service July 21, 
2022, to July 26, 2022. 
 
You asked the Plan to pay for procedure code S9502. You say that you would like the Plan to reconsider their 
denial of payment. The Plan denied your request. The Plan says the billed code is invalid for Medicare 
purposes. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate procedure code. 
 
We find that procedure code S9502 has a Status Indicator of I on the Physician Fee Schedule. This means that procedure code S9502 is not valid for Medicare purposes. Based on this information, we decided that Medicare 
rules for coverage of procedure code S9502 have not been met. Therefore, we decided that the Plan does not 
have to pay for procedure code S9502 billed for date of service July 21, 2022, to July 26, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayments for the inpatient hospital services provided on 
March 7, 2022, to March 11, 2022, an endoscopic bile duct surgery provided on June 14, 2022, and an 
observation stay for gall bladder removal provided from June 21, 2022, to June 22, 2022. 
 
You asked the Plan to waive the copayments for the inpatient hospital services, an endoscopic bile duct 
surgery, and an observation stay for gall bladder removal. You say that you are unable to afford these 
copayments due to a limited income. The Plan denied your request. The Plan says this cost sharing was charged 
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 $325 
copayment per day, days 1-5 for inpatient hospital care, a $275 copayment for Medicare-covered outpatient 
hospital observation, and a $300 copayment for all other outpatient services not provided in an ambulatory 
surgical center. 
 
You have been asked to pay a $1,300 copayment for 4 days of inpatient care ($325 per day x 4 days = $1,300). 
These services fall within the inpatient hospital care benefit category. You have also been asked to pay a $300 
copayment for an endoscopic bile duct surgery, which falls within the outpatient surgery, including services 
provided at hospital outpatient facilities and ambulatory surgical centers, benefit category, and a $275 
copayment for an observation stay for gall bladder removal, which falls within the outpatient hospital 
observation benefit category. This means that you have been asked to pay the correct amount based on your 
contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the 
Plan. Therefore, we decided that the Plan does not have to waive the copayments for the inpatient hospital 
services provided on March 7, 2022, to March 11, 2022, an endoscopic bile duct surgery provided on June 14, 
2022, and an observation stay for gall bladder removal provided from June 21, 2022, to June 22, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the eyeglasses provided on February 9, 2022. 
 You asked the Plan to pay for the eyeglasses. You say that you are appealing this denial. You say you have 
authorization to request the reimbursements for the eyewear. The Plan denied your request. The Plan says no 
referral was obtained which means the services was not authorized. 
 
Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine 
vision and eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in 
this case. The Plan covers these services when authorization is approved. 
 
We looked at the file and the Plan's rules. Specifically, there was no referral for the service. Based on this 
information, we decided that the Plan's rules for coverage of the eyeglasses have not been met. Therefore, we 
decided that the Plan does not have to pay for the eyeglasses provided on February 9, 2022.
Appeal type: Step-Therapy
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Retacrit. 
 
You asked the Plan to pre-approve Retacrit. 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. 
 
Medicare covers Part B medications when they are reasonable and necessary but allows health plans to 
implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain Part B medications. 
 
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 Retacrit. Our reviewer says that the 
services are not medically necessary. Our physician reviewer found in this case, the record indicates that the 
enrollee has anemia due to chronic kidney disease. The requested medication is a new start. The provided 
records do not indicate that the enrollee has tried and failed the plan's preferred step one alternative. The record 
does not indicate that the enrollee has a contraindication to, or would have an adverse effect from the plan's 
preferred step one alternative. The elements of the coverage criteria are not satisfied. The requested service 
cannot be recommended. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Retacrit have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Retacrit.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home health services provided from August 10, 2022, to 
September 8, 2022. 
 
You asked the Plan to pay for the home health services as billed. You say that you would like the Plan to 
reconsider their denial of payment. The Plan denied your request. The Plan says the claim has not been billed 
with the correct admission date. 
 
The Plan follows Medicare rules. The rules say that for home health services that are continuing from 2021, a 
NOA must be submitted for the first period of care in 2022, using the first date of the period as the admission 
date. Subsequent claims must report this new date as the admission date in order for the claim to be matched to the correct NOA.  
 
We reviewed the file and the Medicare rules. We find that the admission date reported on the claim at issue 
does not match the date for the NOA which is filed for the first date in 2022 as required. Based on this 
information, we find that the Medicare rules for payment of the claim at issue have not been met. Therefore, we 
decided that the Plan does not have to pay for the home health services provided from August 10, 2022, to 
September 8, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a stair glide. 
 
You asked the Plan to pay for a stair lift. You say that you would like reconsideration because the requested 
stair lift is medically necessary. The Plan denied your request. The Plan says the requested stair lift is not a 
covered benefit. 
 
The Plan covers all items that Medicare covers. Medicare rules state that stair lifts are not covered because they 
are not primarily medical in nature.  
 
While a stair lift may be appropriate in this case, neither the Plan nor Medicare offers coverage of this item. 
Therefore, we decided that the Plan does not have to pay for a stair glide.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for out of network radiology services 
provided on July 29, 2022, to August 18, 2022. 
 
You asked the Plan to waive the coinsurance for out of network radiology services. You say that this should be 
covered. The Plan denied your request. The Plan says this cost sharing was charged 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 50% 
coinsurance for Basic radiological services. 
 
You have been asked to pay 50% coinsurance for out of network radiology services. This item/service falls 
within the Basic radiological services 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 
out of network radiology services provided on July 29, 2022, to August 18, 2022.
Appeal type: Imaging
Decision: Favorable

 
We decided that the Plan has to pay for a duplex scan of lower extremity arteries provided on March 4, 2022. 
 
You asked the Plan to pay for the duplex scan of lower extremity arteries. You say that the duplex scan of 
lower extremity arteries was medically necessary. The Plan denied your request. The Plan says that this service 
does not meet the coverage requirements in the applicable Local Coverage Determination (LCD) or National 
Coverage Determination (NCD). 
 
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. Specifically, the Plan has not provided the Medicare rule to substantiate the 
denial. Therefore, we decided that the Plan has to pay for a duplex scan of lower extremity arteries provided on 
March 4, 2022.  
 
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.