Persius/hicric huggingface dataset:
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a wireless capsule endoscopy. 
 
You asked the Plan to pre-approve the wireless capsule endoscopy. The Plan denied your request. The Plan 
says your request is not medically necessary because Medicare does not cover capsule endoscopy for the 
evaluation of an elevated alkaline phosphatase. 
 
The Plan follows Medicare rules. Medicare rules say that the indications for wireless capsule endoscopy 
include those who have had upper and lower gastrointestinal (GI) endoscopies within the past 12 months 
(esophagogastroduodenoscopy (EGD) and colonoscopy) that have failed to identify a bleeding source; For 
evaluation of persons with celiac disease with a positive serology and negative biopsy; For re-evaluation of 
persons with celiac disease who remain symptomatic despite treatment and there is no suspected or confirmed 
GI obstruction, stricture, or fistulae; For initial diagnosis in persons with suspected Crohn's disease; and for re-
evaluation of persons with Crohn's disease who remain symptomatic despite treatment and there is no 
suspected or confirmed GI obstruction, stricture, or fistulae. 
 
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 wireless capsule endoscopy. Our 
reviewer says that the enrollee does not meet the provided coverage criteria for wireless capsule endoscopy 
under Local Coverage Determination (LCD) L36427. Our physician reviewer found the enrollee has neither 
undergone recent esophagogastroduodenoscopy (EGD) nor per your opinion is the enrollee symptomatic from 
the gastrointestinal (GI) perspective. Our reviewer also found that no objective data was presented to support 
undue concern for Crohn's disease nor celiac disease. 
 
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 wireless capsule endoscopy have not been met. Therefore, we decided that 
the Plan does not have to pre-approve a wireless capsule endoscopy.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the hereditary cancer genetic panel testing provided on April
9, 2021.

You asked the Plan to pay for the testing services. The Plan denied your request. The Plan says one code must
be submitted for the panel.

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 looked at the file and the rules. The claim shows that the genetic testing panel was billed with multiple
codes. If a single procedure is performed, only one code with one unit of service may be reported for the
procedure. Based on this information, we decided that Medicare rules for coverage of the testing services have
not been met. Therefore, we decided that the Plan does not have to pay for the hereditary cancer genetic panel
testing provided on April 9, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services rendered on June 18, 2021. 
 
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 claim was not billed correctly. 
 
The Plan must follow Medicare rules. The rules say that laboratory shall not report multiple individual CPT 
codes describing the component test results.  
 
We looked at the file and Medicare rules. The file shows that the testing at issue has component test results and was not billed as one test under code 81479. Therefore, we decided that the Plan does not have to pay for the 
laboratory services rendered on June 18, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve impact guards, side guards, and a replacement cover 
(K0108, E2619) for a power wheelchair. 
 
You asked the Plan to pre-approve the items. You say that this is medically necessary. The Plan denied your 
request. The Plan says this is not a covered benefit. 
 
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a 
medical purpose.   
 
The item at issue in this appeal does not serve a purpose that is primarily medical in nature. This item is 
available to the general public and would be helpful even to those who are not sick or injured.  Therefore, we decided that the Plan does not have to pre-approve impact guards, side guards, and a replacement cover (K0108, E2619) for a power wheelchair.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve home health aide (HHA) services (S9122). 
 
You asked the Plan to pre-approve the HHA services. The Plan denied your request. The Plan says the enrollee 
does not meet the criteria established by the Centers for Medicare and Medicaid Services (CMS). The Plan also 
says that the criteria established for coverage of HHA services states that the enrollee must be receiving skilled 
nursing care on an intermittent basis, or physical therapy, speech therapy, or occupational therapy. 
 
The Plan must follow Medicare rules. The rules say that HHA services may be covered if it is medically 
necessary for the enrollee to receive skilled nursing or therapy.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the HHA services. Our reviewer says 
that the HHA services are not medically reasonable and necessary for the enrollee. Our physician reviewer 
found the provided records do not document that the enrollee is receiving skilled nursing care or physical 
therapy, speech therapy, or occupational therapy services. Our reviewer also found that there is no 
documentation that the HHA services are reasonable and necessary for the treatment of the enrollee?s illness or 
injury by the skilled professional staff.  
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 HHA services have not been met. Therefore, we decided that the Plan does 
not have to pre-approve home health aide (HHA) services (S9122).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an auricular neurostimulator. 
 
You asked the Plan to pre-approve an auricular neurostimulator. You say that the requested procedure is a 
medical necessity for the enrollee. The Plan denied your request. The Plan says the requested procedure is not a 
covered benefit. 
 
The Plan must follow Medicare rules. Medicare rules say that electro-acupuncture devices used for stimulation 
of auricular acupuncture points are non-covered. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of an auricular neurostimulator have not been met. Specifically, the requested item is an electro-
acupuncture device which is not a covered benefit. Therefore, we decided that the Plan does not have to pre-
approve an auricular neurostimulator.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an alert or alarm device (A9280). 
 
You asked the Plan to pre-approve an alert device. You say that please reconsider your request for an alert 
device. You are scared to death to move, let alone fall again. The Plan denied your request. The Plan says this 
item is not a covered benefit. 
 
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a 
medical purpose.  
 
The item at issue in this appeal does not serve a purpose that is primarily medical in nature. This item is 
available to the general public and would be helpful even to those who are not sick or injured. Therefore, we 
decided that the Plan does not have to pre-approve an alert or alarm device (A9280).
Appeal type: Lab
Decision: Favorable

 
We decided that the Plan has to pay for pharmacogenomic testing provided on May 3, 2021. 
 
You asked the Plan to pay for pharmacogenomic testing. You say that Medicare has covered this test as 
reasonable and necessary since 2014 and the Plan is required to cover this testing. The Plan denied your 
request. The Plan says that the denial of payment for this testing is correct, because this testing has not been 
shown to be useful, is not considered medically necessary, is not covered by Medicare, and the testing did not 
include the required Z-code. 
 
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. Medicare rules say that a contract provider is an agent of the plan. Services and referrals given by a 
contract provider are considered approved by the plan unless notice is provided that the services will not be 
covered. Medicare rules say that to report a pharmacogenomics testing service, the claim information should 
include the appropriate Current Procedural Terminology (CPT) code, 1 unit of service, the appropriate DEX Z-
Code, and the appropriate International Classification of Diseases 10 Clinical Modification (ICD-10-CM) code. 
   
The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their 
decision to deny your request. The Plan did not specify whether the ordering physician was in-network or out-
of-network with the Plan. The documentation submitted does not include prior notice from the Plan that this 
testing would not be covered. Without this information, we cannot determine whether the lab order made 
constituted plan-directed care. Furthermore, the Plan says that this claim was not billed with the appropriate Z-
Code as required by Medicare rules. However, the Plan did not submit a copy of the original claim form for 
this testing. Without the original claim form, the Plan has not shown that this claim was billed or coded in any 
manner deficient of Medicare's requirements. Therefore, the Plan has not shown that its decision to deny 
payment for this testing is correct or justified according to Medicare rules. Therefore, we decided that the Plan 
has to pay for pharmacogenomic testing provided on May 3, 2021.  
 
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 pay for an oxygen concentrator and supplies provided on June 29, 
2021. 
 
You asked the Plan to pay for an oxygen concentrator and supplies. You say that you should be reimbursed for 
the items at issue. The Plan denied your request. The Plan says rules for payment have not been met because 
the items at issue were purchased, not rented. 
 
The Plan must follow Medicare rules. Medicare rules say that purchased oxygen equipment is statutorily non-
covered. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of an oxygen concentrator and supplies have not been met. Specifically, the items at issue were 
purchased, not rented. Therefore, we decided that the Plan does not have to pay for an oxygen concentrator and 
supplies provided on June 29, 2021.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for Medicare Part B drugs provided on June 
10, 2021. 
 
You asked the Plan to waive the coinsurance for Medicare Part B drugs. You say that you disagree with the 
charges because you have only ever owed a copayment in the past. 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.  
 
You received Medicare Part B drugs on June 10, 2021. The total allowed amount is $1,229.75 and 20% of that 
is $245.95.  
 
 
  
 
You have been asked to pay the total coinsurance amount of $245.95 for Medicare Part B drugs. Medicare Part 
B drugs 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 Medicare Part B drugs provided on June 10, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the dental services provided on May 19, 2021 and June 2, 2021.

You asked the Plan to pay for the dental services. You say that the requirements of being enrolled in Medicare weren't in the policy last year. You say that you had no reason to believe the policy had changed and you are appealing the denial. The Plan denied your request. The Plan says payment cannot be issued for services received from a provider that has opted out of Medicare.

The Plan must follow Medicare rules. The rules say that no Medicare payment may be made to a beneficiary for items or services provided directly by a physician or practitioner who has opted out of the program except in cases involving emergencies or urgently needed care.

The services at issue in this appeal were provided in a non-urgent, non-emergent situation by the provider who has opted out of the Medicare program. Therefore, we decided that the Plan does not have to pay for the dental services provided on May 19, 2021 and June 2, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the periodic comprehensive preventive medicine 
reevaluation and management of an established patient; 65 years and older (99397) rendered by the out-of-
network (OON) provider on July 12, 2021. 
 
You asked the Plan to pay for this service. You say that you are requesting a reconsideration of the Plan's 
denial for payment. The Plan denied your request. The Plan says the service was 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 provider in this case is not a network provider with the Plan. The Plan had network providers available 
who could have provided the service at issue in this appeal. The Plan did not pre-approve the service at issue. 
We found no exception that would require the Plan to pay for this service. Therefore, we decided that the Plan 
does not have to pay for the periodic comprehensive preventive medicine reevaluation and management of an 
established patient; 65 years and older (99397) rendered by the out-of-network (OON) provider on July 12, 
2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for duplex scan of lower extremity arteries or arterial bypass 
grafts (93925) duplex scan of extremity veins including responses to compression and other maneuvers (93970) 
limited bilateral noninvasive physiologic studies of upper or lower extremity arteries (93922) provided on May 
17, 2021 by an out-of-network (OON) provider. 
 
You asked the Plan to pay for the diagnostic services. You say that your services are treated as an emergency 
service in nursing home and home health settings. Insurance carriers do not require portable x-ray suppliers 
across the country to get prior authorization. The Plan denied your request. The Plan says enrollee's must 
receive their medical services from an in-network provider with the exception being urgent or emergent services. Non-emergent services with non-contracted providers require prior authorization before services 
being rendered. 
 
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 had network providers 
available who could have provided 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 duplex scan of lower extremity arteries or arterial 
bypass grafts (93925) duplex scan of extremity veins including responses to compression and other maneuvers 
(93970) limited bilateral noninvasive physiologic studies of upper or lower extremity arteries (93922) provided 
on May 17, 2021 by an out-of-network (OON) provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. You say that you need rehabilitation in an inpatient setting before 
you can climb the stairs to get into your apartment. The Plan denied your request. The Plan says you do not 
need an intensive program with a team of health care professionals and doctors that specialize in rehabilitation, 
or the intense therapies in an acute rehabilitation setting. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 
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 IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our physician reviewer found the complexity of your nursing, medical and rehabilitation needs does not 
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. Our reviewer 
found that you do not require treatment by multiple therapies, including either physical therapy or occupational 
therapy, and an intensive rehabilitation therapy program. While you have a need for physical and/or 
occupational therapy, there is no documentation of a need for an intensive rehabilitation program. Our 
physician reviewer also found that there is not a reasonable expectation that you will be able to fully participate 
in and benefit from the intensive rehabilitation therapy program provided in an IRF. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay more toward the eye exam and refraction provided on July 14, 
2021. 
 
You asked the Plan to pay more toward the eye exam and refraction. You say that you need the extra vision 
care to prevent surgery. You say that this has always been paid by previous insurance and payment should be 
reconsidered. The Plan denied your request. The Plan says the claim processed correctly. 
 
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 a medical eye exam with a $35 copayment and eye refractions are only covered with 
a routine eye exam from a vision Plan provider. 
 
We looked at the file and the Plan's rules. Based on this information, we decided that the Plan's rules for 
additional coverage of the eye exam and refraction have not been met. Therefore, we decided that the Plan does 
not have to pay more toward the eye exam and refraction provided on July 14, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an electro-acupuncture device 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 this device is an electro-acupuncture device placed behind the ear, which is not covered. 
 
The Plan must follow Medicare rules. Medicare rules say that acupuncture for stimulation of auricular points is 
not a covered Medicare benefit. 
 
Electro-acupuncture devices are never covered by Medicare. 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 an electro-acupuncture device for the enrollee.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for ambulance services provided on December 
19, 2020. 
 
You asked the Plan to waive the copayment for ambulance services. You say that you received the services due 
to the coronavirus. You were told that any services related to the coronavirus would be fully covered. 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 a $275 
copayment for ambulance services.  
 
You received ambulance services on December 19, 2020. The coronavirus waiver does not included ambulance 
services. Therefore, you are responsible to pay the $275 copayment.  
 
You have been asked to pay a $275 copayment for ambulance services. Ambulance services fall within the ambulance 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 copayment for ambulance services 
provided on December 19, 2020.