Persius/hicric huggingface dataset:
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve LTACH services. 
 
You asked the Plan to pre-approve the LTACH services. You say that the enrollee is medically stable and 
needs to be transferred to an LTACH versus a lower level of care or remaining in the hospital. You say the 
enrollee will require a multi-disciplinary approach for an extended period of time. The Plan denied your 
request. The Plan says criteria for admission to the LTACH have not been met. 
 
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 has ongoing medical issues and still requires acute care services. The 
enrollee continues to receive acute care services, and these have not been denied. The medical record does not 
indicate that the enrollee requires services that they are not currently receiving but that would be available at 
the LTACH facility. 
 
 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: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the lab services provided on October 24, 2022. 
 
You asked the Plan to pay for the lab services. The Plan denied your request. The Plan says this service was 
billed incorrectly. 
 
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 CPT code 85060 is not payable when provided at an outpatient hospital facility. Based on this 
information, we decided that Medicare rules for coverage of the lab services have not been met. Therefore, we 
decided that the Plan does not have to pay for the lab services provided on October 24, 2022.  
 
 Please note, the documentation in the case file shows that you do not owe any money for this service. If the 
provider is billing you for charges beyond any applicable cost-sharing amounts, please contact the Plan 
directly.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for out-of-network specialist office visits 
provided on May 31, 2022, to September 3, 2022. 
 
You asked the Plan to waive the copayment for out-of-network specialist office visits. You say that you 
disagree with the copayment. 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). The enrollees contract with the Plan clearly says that enrollees 
must pay a $75 copayment per visit for out-of-network physician/practitioner services/specialist.  
 
The enrollee has been asked to pay a $75 copayment per visit for out-of-network specialist office visits. 
However, you are being asked to pay $45 per visit which is less than the required amount for a total of $90 
($45 x 2 visits =$90). This item/service falls within the out-of-network physician/practitioner services/specialist 
benefit category. This means that the enrollee has been asked to pay the correct amount based on the contract with the Plan. This cost sharing is a contractual obligation the enrollee agreed to pay upon enrolling in the Plan. 
Therefore, we decided that the Plan does not have to waive the copayment for out-of-network specialist office 
visits provided on May 31, 2022, to September 3, 2022.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 76942 billed for date of service April 26, 
2022. 
 
You asked the Plan to pay for procedure code 76942. You say that the services were medically necessary. The 
Plan denied your request. The Plan says payment for code 76942 is bundled into payment for code 76536. 
 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, we have confirmed that code 76942 
is a column II code to column I code 76536. This claim has not been billed with an appropriate modifier to 
bypass the edit. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we 
decided that the Plan does not have to pay for procedure code 76942 billed for date of service April 26, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Dexcom continuous glucose monitor (CGM). 
 
You asked the Plan to pre-approve CGM. You say that this is medically necessary. The Plan denied your 
request. The Plan says the Plan only covers Freestyle Libre brand CGMs and will not cover other brands unless 
there is an explanation to support medical necessity for a non-preferred brand. 
 
The Plan must follow Medicare rules. Medicare rules say that plans may limit coverage to certain brands for 
items and supplies. The enrollees contract with the Plan clearly says that the Plan only covers Freestyle Libre 
continuous glucose monitors. The Plan will not cover other brands unless the provider explains that it is 
medically necessary. 
 
We looked at the file and Medicare rules. The requested Dexcom monitor is not the Plans preferred brand. 
There is not an explanation of why this non-preferred brand would be medically necessary. Based on this 
information, we decided that Medicare rules for coverage of CGM have not been met. Therefore, we decided 
that the Plan does not have to pre-approve a Dexcom continuous glucose monitor (CGM).
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care. 
 
You asked the Plan to pre-approve SNF care. You say that the services requested are medically necessary. The 
Plan denied your request. The Plan says the criteria for approval have not been met. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors 
listed in the Medicare rules section are met. Custodial care is not covered.  
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve SNF care. Our reviewer says that the 
requested SNF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found the enrollee does not have daily skilled nursing needs that require the specialized 
skill, knowledge, and judgment of a skilled professional nurse. The enrollee does not have daily skilled therapy 
needs that require the specialized skill, knowledge, and judgment of a skilled professional therapist. The 
enrollee does not require daily skilled nursing and/or skilled therapy on an inpatient basis in a skilled nursing 
facility (SNF) setting. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of SNF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve skilled nursing facility (SNF) care.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99601 billed for date of service September 2, 
2022. 
 
You asked the Plan to pay for procedure code 99601. 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 99601 has a Status Indicator of I on the Physician Fee Schedule. This means that 
procedure code 99601 is not valid for Medicare purposes. Based on this information, we decided that Medicare 
rules for coverage have not been met. Therefore, we decided that the Plan does not have to pay for procedure 
code 99601 billed for date of service September 2, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a manual adult size wheelchair (E1161), cushioned 
headrest (E0955), anti-tipping device (E0971), detachable armrest (E0973), elevating leg rest (E0990), manual 
swingaway, retractable or removable mounting hardware (E1028), wheel lock assembly (E2206), pneumatic 
propulsion tire (E2211), insert for pneumatic propulsion tire (E2213), solid seat support base (E2231), custom 
fabricated wheelchair seat cushion (E2609), custom fabricated wheelchair back cushion (E2617), and 
adjustable angle footplate (K0040). 
 
You asked the Plan to pre-approve a wheelchair and accessories. You say that a standard wheelchair is not able 
to accommodate the needed postural support or safety risk with the enrollee's high risk of falls, nor does it 
allow for extended out of bed tolerance. You also say that it has been deemed medically necessary for the 
enrollee to receive proper equipment to accommodate their needs. The Plan denied your request. The Plan says 
Medicare does not cover durable medical equipment (DME) in a skilled nursing facility (SNF) based on 
statutory definition of DME. 
 The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must be appropriate 
and needed for use inside the home. Medicare does not consider a SNF or a hospital to be a home.  
 
Records show that a wheelchair and accessories is being requested for use in a SNF or hospital. Therefore, we 
decided that the Plan does not have to pre-approve a manual adult size wheelchair (E1161), cushioned headrest 
(E0955), anti-tipping device (E0971), detachable armrest (E0973), elevating leg rest (E0990), manual 
swingaway, retractable or removable mounting hardware (E1028), wheel lock assembly (E2206), pneumatic 
propulsion tire (E2211), insert for pneumatic propulsion tire (E2213), solid seat support base (E2231), custom 
fabricated wheelchair seat cushion (E2609), custom fabricated wheelchair back cushion (E2617), and 
adjustable angle footplate (K0040).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a custom fabricated abutment  includes placement (D6057), 
and abutment supported porcelain fused to metal crown (D6059) provided on November 7, 2022. 
 
You asked the Plan to pay for the custom fabricated abutment (D6057), and abutment supported porcelain 
fused to metal crown (D6059). You say that when you signed up for this coverage you were told that implants 
were covered. You also say that on page 13 of the packet you received it states implants are covered. The Plan 
denied your request. The Plan says these services are not covered under the benefit package. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans 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 pay for a custom 
fabricated abutment  includes placement (D6057), and abutment supported porcelain fused to metal crown 
(D6059) provided on November 7, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the new patient eye exam provided on September 8, 2022. 
 
You asked the Plan to pay for the new patient eye exam. You say that you were unaware that the provider was 
out-of-network. The Plan denied your request. The Plan says the service was not a covered benefit. 
 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 received by a network provider. 
 
We looked at the file and the Plan's rules. Specifically, the provider was out-of-network. Based on this 
information, we decided that the Plan's rules for coverage of the new patient eye exam have not been met. 
Therefore, we decided that the Plan does not have to pay for the new patient eye exam provided on September 
8, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a CardioMEMS HF System (33289). 
 
You asked the Plan to pre-approve a CardioMEMS HF System. You say that you disagree with the denial. The 
Plan denied your request. The Plan says the enrollee's significant problems with medication compliance would 
not be improved simply with implantation of a CardioMEMS. The CardioMEMS device is not medically 
necessary for the enrollee. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
 
 
 
 
 
 
 
 
 We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve a CardioMEMS HF System. Our 
reviewer says that the requested items/services are not considered medically reasonable and necessary in this 
case. Our physician reviewer found the CardioMEMS device was approved by the FDA in 2014 and consists of 
a sensor device placed in the pulmonary artery to allow measurement of pulmonary artery pressure in the 
management of enrollees with CHF. The clinical study on which FDA approval was based showed improved 
clinical outcomes and decreased hospitalizations in enrollees in whom the CardioMEMS system was 
implanted, reflecting an enrollee population with preserved ejection fraction and was somewhat limited in 
scope. Subsequent follow-up studies remain encouraging and suggest an improvement in heart failure 
symptoms with the use of the device. In addition, published expert opinion in the cardiology literature is 
supportive of the clinical usefulness of CardioMEMS. Nonetheless, there remains a dearth of randomized, 
blinded clinical studies examining long-term clinical outcomes establishing the value of CardioMEMS in 
enrollee management. As a result, at this time the CardioMEMS system would not be considered medically 
appropriate and necessary in this enrollee's clinical management. 
 
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 CardioMEMS HF System have not been met. Therefore, we decided that the 
Plan does not have to pre-approve a CardioMEMS HF System (33289).
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for ambulance supplies. 
 
You asked the Plan to pay for the ambulance supplies. You say that you are appealing the denial of services 
provided.  The Plan denied your request. The Plan says the oxygen and oxygen supplies are not covered by 
Original Medicare. 
 
The Plan must follow Medicare rules. Medicare rules say that ambulance supplies are considered part of the 
general ambulance service and payment for them is included in the payment rate for the transport. Therefore, 
we decided that the Plan does not have to pay for ambulance supplies.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 76641 billed for date of service November 7, 
2022. 
 You asked the Plan to pay for procedure code 76641. You say that the enrollee had multiple exams on this date 
of service. The Plan denied your request. The Plan says the number of units billed exceeds the maximum 
allowed. 
 
The Plan must follow Medicare rules. Medicare rules say that claims submitted where the unit of service 
exceeds the MUE value for the HCPCS/CPT code will be denied. 
 
In this case, the MUE for CPT code 76641 is 1. The MAI value for this code is 2. You billed 2 units of this 
code, exceeding the MUE. Specifically, you billed one line item of this code with the LT modifier and one line 
item of this code with the RT modifier instead of billing one line item with the bilateral modifier as is required. 
Based on this information, we decided that Medicare rules for coverage of procedure code 76641 have not been 
met. Therefore, we decided that the Plan does not have to pay for procedure code 76641 billed for date of 
service November 7, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for anesthesia for open or surgical arthroscopic procedures 
provided on January 20, 2022. 
 
You asked the Plan to pay for anesthesia for open or surgical arthroscopic procedures. You say that you are 
appealing the claim payment denial. The Plan denied your request. The Plan says that unauthorized, out-of-
network 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 of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. The Plan 
did not pre-approve the item(s)/service(s) at issue. We found no exception that would require the Plan to pay 
for the item(s)/service(s). Therefore, we decided that the Plan does not have to pay for anesthesia for open or 
surgical arthroscopic procedures provided on January 20, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code S9328 billed for date of service October 8, 
2022, to November 4, 2022. 
 
You asked the Plan to pay for procedure code S9328. You say that continued care was provided to avoid 
complications. 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 S9328 has a Status Indicator of I on the Physician Fee Schedule. This means that 
procedure code S9328 is not valid for Medicare purposes. Based on this information, we decided that Medicare 
rules for coverage have not been met. Therefore, we decided that the Plan does not have to pay for procedure 
code S9328 billed for date of service October 8, 2022, to November 4, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the disposable drug delivery system (A4305) and infusion 
supplies not used with external infusion pump (A4223) provided from September 27, 2022, to September 28, 
2022. 
 
You asked the Plan to pay for the disposable drug delivery system and infusion supplies. You say that you 
would like to be reimbursed for the underpaid charges. The Plan denied your request. The Plan says these 
services are not covered by Medicare. 
 
The Plan must follow Medicare rules. Medicare rules say that disposable drug delivery systems are non-
covered devices, and drugs and supplies used with disposable drug delivery systems are also non-covered 
items. 
 
 
 
 We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the disposable drug delivery system and infusion supplies have not been met. Therefore, we 
decided that the Plan does not have to pay for the disposable drug delivery system (A4305) and infusion 
supplies not used with external infusion pump (A4223) provided from September 27, 2022, to September 28, 
2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the electrocardiogram (ECG) performed by 
an in-network provider on October 13, 2022. 
 
You asked the Plan to waive the copayment for the electrocardiogram (ECG). You say that you do not feel that 
you should have to pay for this service. 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 $105 
copayment for in-network diagnostic procedures and tests performed in an outpatient hospital setting. 
 
 
 
 
 You have been asked to pay a $54.28 copayment for the electrocardiogram (ECG) because the allowed amount 
for this service is less than $105. This item/service falls within the outpatient diagnostic tests and therapeutic 
services and supplies 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 
electrocardiogram (ECG) performed by an in-network provider on October 13, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an insertion of new or replacement of permanent 
pacemaker with transvenous electrode(s); atrial and ventricular (33208). 
 
You asked the Plan to pre-approve a pacemaker replacement. You say that you disagree with the denial. The 
Plan denied your request. The Plan says replacement of the pacemaker currently is not medically necessary. 
The request does not meet the Medicare or health plan coverage criteria. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve a pacemaker replacement. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found at issue is the medical appropriateness and necessity of pacemaker generator 
replacement in this enrollee whose pacemaker has not met ERI criterion, with an estimated battery life of over 
10 months.  As such, the evidence provided would not meet criteria for pacemaker generator replacement. In 
summary, there is insufficient documentation to support the medical necessity for the requested cardiac 
pacemaker in this enrollee's clinical management. 
 
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 pacemaker replacement. have not been met. Therefore, we decided that the 
Plan does not have to pre-approve an insertion of new or replacement of permanent pacemaker with 
transvenous electrode(s); atrial and ventricular (33208).