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

 
We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) services. 
 
You asked the Plan to pre-approve SNF services. You say that these services are medically necessary. The Plan 
denied your request. The Plan says that your needs can be met at a lower level of care. 
 
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 services. Our reviewer says that 
daily skilled services are not necessary. Our physician reviewer found that your condition does not meet 
Medicare criteria for SNF services. 
 
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 services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve skilled nursing facility (SNF) services.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an inpatient hospital stay provided from 
April 7, 2021 to April 15, 2021. 
 
You asked the Plan to waive the copayment for the inpatient hospital stay. You say that the services should be 
covered as you had to stay extra because of the doctors mistakes. The Plan denied your request. The Plan says 
the cost-sharing applied correctly based on the services provided. 
 
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 per day for days 1-6 of Inpatient hospital care.  
 
 
  You have been asked to pay a $1,650 copayment for six days of inpatient hospital care ($275 x 6 = $1,650). 
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 an inpatient hospital stay provided from April 7, 2021 to 
April 15, 2021.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the physical therapy assistant (PTA) services provided in the 
home on September 8, 2021. 
 
You asked the Plan to pay for the PTA services. You say that the services are medically necessary and should 
be paid. The Plan denied your request. The Plan says this is not an appropriate code for the services provided. 
 
The Plan must follow Medicare rules. Medicare rules say that PTA services cannot be billed incident to NPP 
services as the NPP is not considered a therapist.  
 
The NPP is billing for the services of the PTA, which is not allowed per the cited rules. Therefore, we decided 
that the Plan does not have to pay for the physical therapy assistant (PTA) services provided in the home on 
September 8, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services (G0483) provided June 14, 2021. 
 
You asked the Plan to pay for the lab services. You say that the lab services were medically necessary. The 
Plan denied your request. The Plan says the documentation does not support the claim as billed. 
 
The Plan must follow Medicare rules. Medicare rules say that lab services, the POS code must reflect the 
location in which the sample was taken. POS code 81 is used to describe samples taken by the laboratory 
directly. 
 
 We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the lab services have not been met. Specifically, this claim was billed with the laboratory POS 
code. The records do not support that the sample was taken in a laboratory setting. Therefore, we decided that 
the Plan does not have to pay for lab services (G0483) provided June 14, 2021.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve thermal destruction of intraosseous basivertebral nerve 
for the enrollee. 
 
You asked the Plan to pre-approve the procedure. You say that this is medically necessary. The Plan denied 
your request. The Plan says this is considered investigational. 
 
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 the procedure. Our reviewer says that 
the requested services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found the back pain, pain-aggravating and pain-relieving factors, along with the diminished and 
painful spinal motion (in all directions) and intact neurologic exam were/are all non-specific to any pathologic 
entities. Overall, documentation was/is lacking regarding reasonably detailed and/or evidenced findings 
supportive of the spinal vertebral bodies as being the overwhelming primary generators of the enrollees 
chronic persistent pain. Documentation does not support actual formal surgical ablation of pre-designated 
basivertebral nerves as being medically necessary and/or reasonable at this time. 
 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 procedure have not been met. Therefore, we decided that the Plan does not 
have to pre-approve thermal destruction of intraosseous basivertebral nerve for the enrollee.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the Guardant360 CDx testing provided on April 17, 2021. 
 
You asked the Plan to pay for the Guardant360 CDx testing. You say that this is correctly billed with POS 81. 
The Plan denied your request. The Plan says the POS code reported is not appropriate. 
 
The Plan must follow Medicare rules. Medicare rules say that lab services, the POS code must reflect the 
location in which the sample was taken. POS code 81 is used to describe samples taken by the laboratory 
directly. 
 We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the Guardant360 CDx testing have not been met. Specifically, this claim was billed with the 
laboratory POS code. The records do not support that the sample was taken in a laboratory setting. Therefore, 
we decided that the Plan does not have to pay for the Guardant360 CDx testing provided on April 17, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve diagnostic casts (D0470), endosteal implants (D6010), 
bone grafts at time of implant placement (D6104), and radiographic/surgical implant indexes (D6190). 
 
You asked the Plan to pre-approve diagnostic casts, endosteal implants, bone grafts, and radiographic/surgical 
implant indexes. The Plan denied your request. The Plan says these services are not covered under your benefit 
plan. 
 
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 pre-approve 
diagnostic casts (D0470), endosteal implants (D6010), bone grafts at time of implant placement (D6104), and 
radiographic/surgical implant indexes (D6190).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for wound debridement services provided from 
October 27, 2021, to December 1, 2021. 
 
You asked the Plan to waive the copayment for the wound debridement services. You say that the services 
should be covered at a higher rate as they were 5 minute long procedures. The Plan denied your request. The 
Plan says the cost-sharing applied correctly based on the services provided, these services fall under the 
surgical category. 
 
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 $150 
copayment for Outpatient hospital services.  
 
 You have been asked to pay a $466.12 copayment for 4 wound debridement service visits, which is less than 
the standard $150 copayment per visit. Wound debridement services fall within the Outpatient hospital 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 wound debridement services 
provided from October 27, 2021, to December 1, 2021.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for physical therapy services provided on 
October 20, 2021. 
 
You asked the Plan to waive the copayment for the physical therapy services. You say that the services should 
be covered as you called the Plan beforehand and were advised the provider was in-network. The Plan denied 
your request. The Plan says the cost-sharing applied correctly based on the services provided. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $20 
copayment for Outpatient rehabilitation services.  
 
 
  You have been asked to pay a $20 copayment for the physical therapy services. Physical therapy services fall 
within the Outpatient rehabilitation 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 physical therapy services provided on October 20, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to reimburse you for eyeglass deluxe frames (V2025) and progressive 
lenses (D2781) provided on August 26, 2021. 
 
You asked the Plan to reimburse you for eyeglass deluxe frames and progressive lenses. You say that you 
disagree with the denial because you have $500 available for the purchase of eyewear. You also say that you 
received reimbursement for one pair of glasses, and you hope to receive payment for the other. The Plan denied 
your request. The Plan says you were reimbursed properly according to your plan benefits. 
 
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 contract says that you receive a $500 (combined in and out-of-network) benefit toward the 
purchase and fitting of eyeglasses and pair of lenses or contact lenses, 1 per calendar year. 
 
We looked at the file and the Plan's rules. The EOC confirms you receive a $500 benefit towards the purchase 
of one eyeglass frame and lens per calendar year. The records show that you purchased two eyeglass frames 
and lenses. The Plan paid for the first pair and you are responsible for the second pair. Based on this 
information, we decided that the Plan's rules for coverage of eyeglasses deluxe frames and progressive lenses 
have not been met. Therefore, we decided that the Plan does not have to reimburse you for eyeglass deluxe 
frames (V2025) and progressive lenses (D2781) provided on August 26, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

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

 
We decided that the Plan does not have to pre-approve a pneumatic compression device (E0652). 
 
You asked the Plan to pre-approve a pneumatic compression device. You say that this device is medically 
necessary for the enrollee's condition. The Plan denied your request. The Plan says the criteria for coverage 
have not been satisfied. 
 
The Plan follows Medicare rules. The rules state that a PCD coded as E0652 is covered for the treatment of 
lymphedema extending onto the chest, trunk and/or abdomen after a four-week trial of conservative therapy 
demonstrating failed response to treatment with an E0650 or E0651. At least four weeks of regular, daily, 
multiple-hour home usage of the E0650 or E0651 is required. 
 
We 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 for the pneumatic compression device. Our reviewer 
says that the requested pneumatic compression device is not medically reasonable and necessary according to 
the Medicare rules. Our physician reviewer found that the documentation indicates that the appellant is 
requesting reconsideration stating services are medically necessary. Prior conservative treatments that have 
been tried including elevation, exercise, compression garments, manual lymph drainage, and patient education 
lymphedema management. Despite these conservative treatments, the patient continues to present severe and 
chronic Lymphedema. Despite the therapies over the 4 weeks, as attested to by the signed Letter of Medical 
Necessity, the symptoms persist. In this case, the records do not show that the enrollee has truncal edema and 
there is no documentation indicating a four-week trial of a non-segmental or a segmental model without 
calibrated gradient pressure PCD (E0650 or E0651). The review has determined that the enrollee does not 
satisfy the coverage criteria for the pneumatic compression device. 
 
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 PCD have not been met. Therefore, we decided that the Plan does not have 
to pre-approve a pneumatic compression device (E0652).
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 ready for transfer and 
requires extended acute care. You say that an LTACH is the appropriate level of care. The Plan denied your 
request. The Plan says the member is getting acute care and acute care services have not been denied. 
 
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 that the member is improving and should only require short-term additional acute 
care services that can safely be administered at the current facility. There are no services at the LTACH that are 
not already available and covered at the current 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 LTACH services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Fitbit device. 
 
You asked the Plan to pre-approve the device. You say that this is needed to keep up with your steps and 
activity. 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 a Fitbit device.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a computed tomography (CT) scan of the pelvis (72192) 
provided on November 17, 2012. 
 
You asked the Plan to pay for a CT scan of the pelvis. You say that you have provided records to support the 
level of service. The Plan denied your request. The Plan says rules for payment have not been met because the 
code at issue is inclusive to another billed code. 
 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 72192 
is a column II code to column I code 74176. 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 a computed tomography (CT) scan of the pelvis (72192) 
provided on November 17, 2012.
Appeal type: Surgery
Decision: Favorable

 
We decided that the Plan has to pay for the additional 14 units of adjacent tissue transfer or rearrangement 
(14302) provided on February 17, 2021. 
 
You asked the Plan to pay for the additional 14 units of adjacent tissue transfer or rearrangement. You say that 
the additional units billed were medically reasonable and necessary. The Plan denied your request. The Plan 
says that payment cannot be made for the additional units beyond what has been paid based on the MUE. 
 
The Plan follows Medicare rules. Medicare rules say that MAIs of 3 are per day edits to indicate it is possible 
but highly medically unlikely that higher values would represent correctly reported medically necessary 
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 pay for the additional 14 units of adjacent tissue 
transfer or rearrangement. Our reviewer says that the documentation supports that the additional units of CPT 
code 14302 were medically reasonable and necessary. Our physician reviewer found the enrollee is a 65-year-
old woman with a right foot wound with exposed bone following resection of a sarcoma, who underwent 
irrigation and excisional debridement, first stage sural flap reconstruction, adjacent tissue transfer partial 
reconstruction of sural flap donor site, adjacent tissue transfer partial reconstruction of medial foot defect, and 
application of a wound vacuum-assisted culture (VAC). The CMS MUE file lists the MUE for code 14302 as 
8.  The operative report clearly documents an adjacent tissue transfer partial reconstruction of sural flap donor 
site of 27 x 24 cm, for a total of 648 sq.cm. This is compelling medical evidence as to why more than 8 units of 
this code should be billed on this single date of service. The documentation supports that the additional billed 
units beyond the MUE of 8 were medically reasonable, necessary and appropriate in this case. 
 
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 additional 14 units of adjacent tissue transfer or rearrangement have been 
met. Therefore, we decided that the Plan has to pay for the additional 14 units of adjacent tissue transfer or 
rearrangement (14302) provided on February 17, 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: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an out-of-network referral for magnetic resonance 
imaging (MRI). 
 
You asked the Plan to pre-approve the referral. You say that this is medically necessary. The Plan denied your 
request. The Plan says there are in-network servicing providers. 
 
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 
an out-of-network referral for magnetic resonance imaging (MRI).