Persius/hicric huggingface dataset:
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for pain management services provided to the enrollee on 
November 8, 2021. 
 
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. 
The Plan says the plan has not received the required clinical records to support the medical necessity of this 
service.  
The Plan must follow Medicare rules. Medicare rules say that the provider, supplier, or beneficiary, as 
appropriate, must furnish to the intermediary or carrier sufficient information to determine whether payment is 
due and the amount of payment. 
 
We looked at the file and Medicare rules. Based on this information, we decided that there is insufficient 
information in the record to determine if Medicare rules for coverage of pain management services provided to 
the enrollee on November 8, 2021 have been met. The records sent in by the provider are incomplete, as they 
are unsigned and undated. The services cannot be verified in this case. Therefore, we decided that the Plan does 
not have to pay for pain management services provided to the enrollee on November 8, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for ankle foot orthoses (L1971) and plastic heel stabilizers 
(L3170) provided on December 8, 2021. 
 
You asked the Plan to pay for ankle foot orthoses and plastic heel stabilizers. You say that the requested items 
were a medical necessity for the enrollee. The Plan denied your request. The Plan says rules for payment for 
DMEPOS have not been met. 
 
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 relevant medical records which support medical necessity for the supplies provided 
in this case. The available medical records do not discuss the items at issue. 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 ankle foot orthoses (L1971) and plastic heel stabilizers (L3170) provided on 
December 8, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to waive the cost-sharing for the eye exam (92014) and eye refraction 
(92015) provided on January 11, 2022. 
 
You asked the Plan to waive the cost-sharing for the vision services. You say that you should not be 
responsible for these payments. The Plan denied your request. The Plan says this claim was processed 
correctly, and your share of the cost was assessed in accordance with your contract. You are responsible for a 
$35 copayment for each exam to diagnose and treat diseases and conditions of the eye. In addition, the eye 
refraction was provided in conjunction with a medical eye exam, which means that it is not covered by 
Medicare or by the Plan. 
 
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 eye refractions only when they are provided as part of a routine (non-medical) eye 
exam. 
 
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 exams to diagnose and treat diseases and conditions of the eye.  
 
We looked at the file and the Plans rules. The medical records indicate that the eye exam in question was 
provided for medical purposes and not as a routine eye exam only for the purposes of a prescription of 
eyeglasses/contacts. You have been asked to pay a $35 copayment for the eye exam, which falls within the 
exams to diagnose and treat diseases and conditions of the eye benefit category. In addition, you are 
responsible for the full cost of the eye refraction, as this service is only covered when it is performed in 
conjunction with a routine eye exam. This service is not covered when provided with a medical eye exam. 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 cost-sharing for the eye exam (92014) and eye refraction (92015) provided 
on January 11, 2022.
Appeal type: Hospice
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the hospital discharge day management (99239) provided on 
December 25, 2021. 
 
You asked the Plan to pay for the evaluation and management service. You say that the services were 
medically necessary. The Plan denied your request. The Plan says the enrollees claim would be covered under 
Original Medicare as it is responsible for coverage of Part B benefits starting on the date of election until the 
last day of the month in which hospice is revoked. The Plan also says it is the providers responsibility to verify 
the enrollees coverage before rendering services and to know proper billing procedures for a Medicare 
Advantage member on hospice. 
 Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice 
services. Medicare hospice pays for claims related to the terminal illness. The rules say that the Plan may direct 
the provider to bill Medicare directly for these services.  
 
The enrollee was under the Medicare hospice benefit for the dates of service at issue in this appeal. Therefore, 
we decided that the Plan does not have to pay for the hospital discharge day management (99239) provided on 
December 25, 2021.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an additional 36 routine transportation trips (A0120). 
 
You asked the Plan to pre-approve an additional 36 routine transportation trips. You say that you need 
transportation to chemotherapy sessions. The Plan denied your request. The Plan says you have utilized the 
maximum number of transportation trips allowed per year. 
 
Medicare does not cover transport in a vehicle that is not an ambulance. However, the Plan offers a 
transportation benefit that exceeds Medicare coverage. For that reason, the Plans coverage rules apply in this 
case. The Plan covers a maximum of 24 trips per year.  
 We looked at your request, the records in the case file, and the rules. Based on this information, we decided 
that you have exhausted the Plan maximum benefit for coverage of routine transportation. Therefore, we 
decided that the Plan does not have to pre-approve an additional 36 routine transportation trips (A0120).
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 admission to an LTACH is medically 
necessary. The Plan denied your request. The Plan says the admission to an LTACH is not medically 
necessary. 
 
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 there are no services available at the LTACH that the enrollee requires that are not 
available and being provided at the health care setting being offered by the health plan. 
 
 
 
 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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a manual adult size wheelchair with tilt space and 
accessories. 
 
You asked the Plan to pre-approve a manual adult size wheelchair with tilt space and accessorie. You say that 
the items are medically necessary. The Plan denied your request. The Plan says these items are not covered 
when provided in a skilled nursing facility. 
 
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 manual adult size wheelchair with tilt space and accessorie 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 with tilt space and accessories.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the radiologic examination, abdomen; 1 view (CPT code 
74018-26) provided on December 13, 2021.  
You asked the Plan to pay for the service. You say that the claim should be paid. The Plan denied your request. 
The Plan says the records submitted do not indicate that two separate services were performed/supported. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
The medical records with radiology reports are identical in notation and times. Based on this information, we 
decided that Medicare rules for coverage of the service have not been met. Therefore, we decided that the Plan 
does not have to pay for the radiologic examination, abdomen; 1 view (CPT code 74018-26) provided on 
December 13, 2021.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the application of skin substitute graft (15271, Q4186, 
Q4187). 
 
You asked the Plan to pre-approve the application of skin substitute graft. You say that the requested services 
are a medical necessity for the enrollee. The Plan denied your request. The Plan says rules for coverage have 
not been met because the requested services are experimental/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 application of skin substitute graft. 
Our reviewer says that the requested services are not considered medically reasonable and necessary in this 
case. Our physician reviewer found that it appears the enrollee is experiencing improvement, albeit gradual, 
with current treatment, which should be continued. Also, there is insufficient high-quality evidence from 
studies to show a clear overall outcome benefit using skin substitute treatment in the enrollee's clinical 
situation. 
 
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 application of skin substitute graft have not been met. Therefore, we decided 
that the Plan does not have to pre-approve the application of skin substitute graft (15271, Q4186, Q4187).
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Omeprazole 40 mg capsule. 
 
You asked the Plan to pre-approve Omeprazole. You say that this drug is medically necessary for the enrollee's 
condition. The Plan denied your request. The Plan says this drug is not covered under the enrollee's medical 
benefit. 
 
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-
administered drugs. The self-administered drugs requested here are not among the types which are covered by 
Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve Omeprazole 40 mg capsule.  
 Benefits for Omeprazole may be available under Medicare Part D. Contact the Plan that administers Part D 
benefits for further information concerning any benefits and appeal rights.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the Tempus Gene Panel (81206, 81235, 81292, 81298, 
81317, 81321, 81402, and 81301) provided on August 12, 2021. 
 
 
You asked the Plan to pay for the Tempus Gene Panel. You say that you would like reconsideration because 
this panel is useful for patients at initial diagnosis or for a patient with refractory disease. The Plan denied your 
request. The Plan says Medicare denies coverage when a laboratory assays two or more genes in a patient in 
parallel. 
 
The Plan must follow Medicare rules. Medicare rules say that the submission of claims using individual gene 
CPT codes, when either 5-50 or >50 gene panels are ordered, is considered incorrect coding. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the Tempus Gene Panel have not been met. Specifically, it is not appropriate to bill this panel with 
individual gene codes. Therefore, we decided that the Plan does not have to pay for the Tempus Gene Panel 
(81206, 81235, 81292, 81298, 81317, 81321, 81402, and 81301) provided on August 12, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the hearing aids provided on November 5, 2021. 
 
You asked the Plan to pay for the hearing aids. You say that you should be reimbursed some of the cost if they 
are premium devices. The Plan denied your request. The Plan says the hearing aids must be purchased through 
the Plan's hearing vendor, and you must register with them prior to receiving the hearing aids. 
 
Medicare does not pay for hearing aids or related services. However, the Plan offers a hearing aid benefit that 
exceeds Medicare coverage. For that reason, the plans coverage rules apply in this case. The Plan pays for 
hearing aids only when they are received from the Plan's hearing aid vendor.  
 
We looked at the file and the Plan's rules. Based on this information, we decided that the Plan's rules for 
coverage of the hearing aids have not been met. Specifically, the hearing aids were not purchased from the 
Plans hearing aid vendor. Therefore, we decided that the Plan does not have to pay for the hearing aids 
provided on November 5, 2021.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the radiology services, provided on March 18, 2021 by an 
out-of-network (OON) provider. 
 
You asked the Plan to pay for the radiology services. You say that the services should be covered. The Plan 
denied your request. The Plan says this service is not covered when obtained out-of-network. 
 
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 the radiology services, provided on March 18, 
2021 by an out-of-network (OON) provider.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the nursing care, in the home (S9124) provided on November 
6, 2020. 
 
You asked the Plan to pay for the nursing care. You say that the medical records show this service was 
medically necessary. The Plan denied your request. The Plan says the submitted code for service, S9124, is a 
status I code, which is not a valid code for Medicare services. 
 
The Plan must follow Medicare rules. Medicare rules say that procedure code S9124 is not valid for Medicare 
purposes and is not payable. 
 
 
 
 
 
 
 We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the nursing care have not been met. Therefore, we decided that the Plan does not have to pay for 
the nursing care, in the home (S9124) provided on November 6, 2020.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for imaging services provided to the enrollee on December 3, 
2021. 
 
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. 
The Plan says an appropriate modifier was not billed with this edit. 
 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 70450 
is a column II code to column I code 70496. 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 imaging services provided to the enrollee on December 3, 2021.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the abdominal ultrasound (76705) provided on January 12, 
2022. 
 
You asked the Plan to pay for the ultrasound. You say that the enrollee had multiple exams on the date in 
question. The Plan denied your request. The Plan says a National Correct Coding Initiatives (NCCI) Procedure 
to Procedure (PTP) edit exists between 93976 and 76705. This PTP edit has a modifier indicator of 1, meaning modifiers associated with NCCI are allowed. However, an appropriate modifier was not billed with this PTP 
code edit. This service was not billed as required by Medicare coding regulations. 
 
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 76705 
is a column II code to column I code 93976. 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 the abdominal ultrasound (76705) provided on January 12, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the hot or cold packs therapy (97010) provided on December 
3, 2021. 
 
You asked the Plan to pay for the hot or cold packs therapy (97010). You say that the claim was denied due to 
no authorization, but you have authorization on file. The Plan denied your request. The Plan says CPT codes 
97112, 97530 and 97110 have been reprocessed. The Plan also says that CPT code 97010 remains denied as 
bundled services are not eligible for separate reimbursement.  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 97010 has a status indicator of B on the Physician Fee Schedule. This means that CPT 
code 97010 is not separately payable. Based on this information, we decided that Medicare rules for coverage 
of the hot or cold packs therapy (97010) have not been met. Therefore, we decided that the Plan does not have 
to pay for the hot or cold packs therapy (97010) provided on December 3, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for anticoagulant management provided on March 15, 2022, by 
an out-of-network (OON) provider. 
 
You asked the Plan to pay for anticoagulant management. You say that the service was medically necessary. 
The Plan denied your request. The Plan says no prior authorization was obtained. 
 
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 did not pre-approve the 
item/service at issue. We found no exception that would require the Plan to pay for these items/services. The 
records provided for review do not show that the service at issue was urgent or emergent. Therefore, we 
decided that the Plan does not have to pay for anticoagulant management provided on March 15, 2022, 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 these services are medically necessary. The Plan 
denied your request. The Plan says that records do not show you need an intensive program with a team of 
health care professionals and doctors that specialize in complex medical needs as well as rehab. 
 
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. The 
complexity of your nursing, medical and rehabilitation needs do not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. You were admitted for thoracic compression fractures. 
Your medical problems are stable. There are no complex nursing or rehabilitation needs. 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. 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. Our physician reviewer found that your condition does not meet Medicare criteria for IRF care. 
 
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.