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

 
We decided that the Plan does not have to pay for the plastic ankle foot orthosis (AFO) and related soft 
interface provided on September 30, 2021, billed with codes L1930 and L2820. 
 
You asked the Plan to pay for the AFO and related interface. You say that this claim should be paid. The Plan 
denied your request. The Plan says the documentation does not support the medical necessity of these items. 
 
The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when there are both a 
physician order and proof of delivery.  
 
The record does not contain a valid proof of delivery or relevant medical records which support medical 
necessity for the supplies provided in this case. The record shows that the Plan made several attempts to obtain 
the proof of delivery. In addition, the medical records do not show any intent to prescribe an AFO or any 
condition for which it would be used. Therefore, we decided that the Plan does not have to pay for the plastic ankle foot orthosis (AFO) and related 
soft interface provided on September 30, 2021, billed with codes L1930 and L2820.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Saxenda. 
 
You asked the Plan to pre-approve Saxenda. You say that Saxenda is medically necessary for the enrollee to 
achieve their weight loss requirements. The Plan denied your request. The Plan says Saxenda is on the self-
administered drug list and is excluded from coverage under Part B. 
 
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 Saxenda.  
 
Benefits for Saxenda 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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the critical care services coded 99291 provided on July 22, 
2021. 
 
You asked the Plan to pay for the critical care services. You say that you disagree with the Plan's denial. The 
Plan denied your request. The Plan says the services billed are not payable. 
 The Plan must follow Medicare rules. Medicare rules say that claims submitted where the unit of service 
exceeds the MUE value cannot be paid when the MAI value is 2.  
 
In this case, the MUE for CPT code 99291 is 1. The MAI value for this code is 2. You billed 3 units of this 
code, exceeding the MUE. Based on this information, we decided that Medicare rules for coverage of the 
critical care services have not been met. Therefore, we decided that the Plan does not have to pay for the 
critical care services coded 99291 provided on July 22, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the eye exam (92004) and computerized 
ophthalmic diagnostic imaging (92134) provided on March 22, 2022. 
 
You asked the Plan to waive the copayment for the eye exam and computerized ophthalmic diagnostic imaging. 
You say that you are upset that you were given misinformation. The Plan denied your request. The Plan says 
the copayment amount you are being charged is correct. The Plan also says that there is no indication you 
contacted the Plan prior to this date of service to verify benefits, and no misinformation was provided by the 
Plan. 
 
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 $75 
copay for diagnostic procedures and tests, and a $48 copay for all other physician services to diagnose and treat 
diseases and conditions of the eye.  
 You have been asked to pay a $48 copayment for the eye exam. You have also been asked to pay $27 for the 
ophthalmic imaging, which is less than the standard $75 copayment. The eye exam and computerized 
ophthalmic diagnostic imaging fall within the Outpatient diagnostic tests and Vision care benefit categories. 
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 eye exam (92004) and computerized ophthalmic 
diagnostic imaging (92134) provided on March 22, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the implantation of mesh or other prosthesis services coded 
49568 provided on December 4, 2021. 
 
You asked the Plan to pay for the implantation of mesh or other prosthesis services. You say that you disagree 
with the Plan's denial. The Plan denied your request. The Plan says the services are not payable as billed. 
 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 49568 
is an add-on code and has not been billed with an appropriate primary procedure code. 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 implantation of mesh or other prosthesis services coded 49568 provided on December 4, 2021.
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 therapy to help get mobile again. The Plan 
denied your request. The Plan says that you can safely receive the services you need in other settings. 
 
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. You 
are medically stable and do not need physical medicine and rehabilitation physician's close supervision 3 times 
per week (at a minimum) for the ongoing management of any active or acute exacerbations of chronic medical conditions. There are no acute nursing needs identified or documented. At the current functional level, you do 
not need therapy 3 hours a day, 5 days a week as you will not make a significant functional improvement in a 
short term acute IRF. While you would benefit from physical and occupational therapy, your rehab needs can 
be safely provided in an alternate and low intensity setting. 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.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to waive the deductible for the MRI provided on March 22, 2022. 
 
You asked the Plan to waive the deductible for the MRI. You say that there is only a copayment at a 
freestanding radiological facility. The Plan denied your request. The Plan says this claim was processed 
correctly. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information. Your 
contract with the Plan says that there is a $1,005 deductible which applies to the MRI. 
 
The item or service you asked the Plan to waive the deductible for falls within the Outpatient Diagnostic Tests 
and Therapeutic Services and Supplies benefit category. The Plan has followed Medicare rules by clearly 
disclosing in the contract that there is a $1,005 deductible which applies to the MRI. This cost sharing is a 
contractual obligation that had not been met at the time the MRI was received on March 22, 2022. Therefore, 
we decided that the Plan does not have to waive the deductible for the MRI provided on March 22, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services related to end-stage renal disease 
(ESRD) provided on January 24, 2022. 
 
You asked the Plan to pay for the ESRD-related laboratory services. You say that there is no contract in place 
that indicates that these tests are included in payment for dialysis. The Plan denied your request. The Plan says 
Medicare does not separately pay for ESRD-related laboratory testing. 
 
The Plan must follow Medicare rules. Medicare rules state that routine ESRD laboratory services are not 
separately payable. Laboratories should bill the facility directly for laboratory services as they are considered 
part of the composite rate. No other payment for these services is allowed. Therefore, we decided that the Plan 
does not have to pay for the laboratory services related to end-stage renal disease (ESRD) provided on January 
24, 2022.
Appeal type: Imaging
Decision: Favorable

 
We decided that the Plan has to pay for a second chest x-ray provided to the enrollee on February 10, 2022. 
 
You asked the Plan to pay for the x-ray. You say that this should be paid for. The Plan denied your request. The 
Plan says that 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. In this case, the CPT Code Manual definition of 
code 71045 is "Radiologic examination, chest; single view. 
 
We asked our coder 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 x-ray. Our reviewer says that the services at issue in this 
case were supported by the medical records. Our reviewer found that the provider's coding is correct in this 
case. The documentation submitted supports the use of procedure code 71045. If the provider did perform 
twice, then the modifier would be appropriate. However, the professional claim and the technical component 
are different, and both deserve separate reimbursement. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the x-ray have been met. Therefore, we decided that the Plan has to pay for a 
second chest x-ray provided to the enrollee on February 10, 2022.  
 
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again 
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake 
and/or send us the new information. This does not happen often. If we decide to open the case again, we will 
send you a letter.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services related to end-stage renal disease 
(ESRD) provided on January 14, 2022. 
 
You asked the Plan to pay for the ESRD-related laboratory services. You say that there is no contract in place 
which indicates that the billed tests are included in the dialysis rate. The Plan denied your request. The Plan 
says Medicare does not separately pay for ESRD-related laboratory testing. 
 
The Plan must follow Medicare rules. Medicare rules state that routine ESRD laboratory services are not 
separately payable. Laboratories should bill the facility directly for laboratory services as they are considered 
part of the composite rate. No other payment for these services is allowed. Therefore, we decided that the Plan 
does not have to pay for the laboratory services related to end-stage renal disease (ESRD) provided on January 
14, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for progressive lens  premium tier 3 (V2781), polycarbonate 
(V2784), vision item or service, miscellaneous (V2799), anti-reflective coating, per lens (V2750), frames 
(V2020) and vision supply, accessory and/or service component of another HCPCS vision code (V2797). 
 
You asked the Plan to pay for progressive lens  premium tier 3, polycarbonate, vision item or service, 
miscellaneous, anti-reflective coating, per lens, frames and vision supply, accessory and/or service component 
of another HCPCS vision code. The Plan denied your request. The Plan says the total cost share applied as the 
members responsibility applied 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. 
 
We looked at the file and the Plan's rules. Based on this information, we decided that the Plan's rules for 
coverage of progressive lens  premium tier 3, polycarbonate, vision item or service, miscellaneous, anti-
reflective coating, per lens, frames and vision supply, accessory and/or service component of another HCPCS 
vision code. have not been met. Therefore, we decided that the Plan does not have to pay for progressive lens  
premium tier 3 (V2781), polycarbonate (V2784), vision item or service, miscellaneous (V2799), anti-reflective 
coating, per lens (V2750), frames (V2020) and vision supply, accessory and/or service component of another 
HCPCS vision code (V2797) provided April 6, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve insertion or replacement of peripheral or gastric 
neurostimulator pulse generator or receiver, direct or inductive coupling (CPT code 64590). 
 
You asked the Plan to pre-approve the service. You say that the service is medically necessary. The Plan 
denied your request. The Plan says the information they have been provided shows that you have not submitted 
a voiding diary. 
 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 service. Our physician reviewer 
found enrollees with neurologic diseases are excluded for Sacral nerve stimulation coverage. In this case, the 
enrollee has neurogenic bladder due to a spinal cord injury. As such, the medical records provided do meet the 
requirements listed in the NCD for Medicare coverage. 
 
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 service have not been met. Therefore, we decided that the Plan does not 
have to pre-approve insertion or replacement of peripheral or gastric neurostimulator pulse generator or 
receiver, direct or inductive coupling (CPT code 64590).
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the home health PT visits (CPT code G0151 x2). 
 
You asked the Plan to pre-approve the home health PT visits. You say that the services are necessary. The Plan 
denied your request. The Plan says the enrollee's request is not medically necessary because the enrollee's 
records show they no longer have a need for home physical therapy services and have completed the enrollee's 
course of therapy with all goals met. 
 
The Plan must follow Medicare rules. The rules say that home health care services may be covered if it is 
medically necessary for the enrollee to receive skilled nursing or therapy. A doctor must certify the need for home health care 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 pre-approve the home health PT visits. Our 
physician reviewer found the health plans denial should be upheld. The enrollee does not have documented 
skilled PT needs. The enrollee is functioning at a level commiserate with a lower level of care. As such, the 
requested, home health PT services are not medically necessary or reasonable. 
 
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 home health PT visits have not been met. Therefore, we decided that the 
Plan does not have to pre-approve the home health PT visits (CPT code G0151 x2).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services provided on January 26, 2022. 
 
You asked the Plan to pay for the lab services. You say that these services were necessary and were billed 
appropriately. The Plan denied your request. The Plan says you billed with an incorrect place of service on the 
claim. 
 
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 provided on January 26, 2022.
Appeal type: Lab
Decision: Favorable

 
We decided that the Plan has to pay for the FoundationOne testing provided on February 10, 2022. 
 
You asked the Plan to pay for the testing services. You say that the test is necessary for the management of the 
enrollee's advanced cancer. The Plan denied your request. The Plan says that the test is not a covered benefit. 
 
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. 
 
We looked at the file and the rules. The testing at issue was provided to the enrollee with a solid tumor. The 
FDA approval notice indicates that this panel is approved for solid tumors. No other valid denial rationale was 
presented by the Plan. The Plan has not made reasonable and diligent efforts to gather and forward to us 
information regarding their decision to deny your request.  Therefore, we decided that the Plan has to pay for 
the FoundationOne testing provided on February 10, 2022.  
 
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again 
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake 
and/or send us the new information. This does not happen often. If we decide to open the case again, we will 
send you a letter.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laparoscopy services coded 47562 provided on 
September 9, 2021. 
 
You asked the Plan to pay for the laparoscopy services. You say that you disagree with the Plan's denial. The 
Plan denied your request. The Plan says the services billed are not payable. 
 The Plan must follow Medicare rules. Medicare rules say that claims submitted where the unit of service 
exceeds the MUE value cannot be paid when the MAI value is 2.  
 
In this case, the MUE for CPT code 47562 is 1. The MAI value for this code is 2. You billed 2 units of this 
code, exceeding the MUE. Based on this information, we decided that Medicare rules for coverage of the 
laparoscopy services have not been met. Therefore, we decided that the Plan does not have to pay for the 
laparoscopy services coded 47562 provided on September 9, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a continuous glucose monitor (CGM) and supplies. 
 
You asked the Plan to pre-approve a CGM and supplies. You say that the items are necessary. The Plan denied 
your request. The Plan says based on the documentation provided, coverage criteria has not been met. 
 
The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are considered medically 
reasonable and necessary for enrollees with diabetes who use insulin with at least three daily administrations, 
require frequent self-adjustment of insulin dosage based on the blood glucose testing results and have had an 
in-person visit with their treating physician to assess adherence to their CGM regimen and diabetes treatment 
plan. 
 
We looked at the file and Medicare rules. The documentation indicates that you do not use insulin with at least 
three daily injections. Based on this information, we decided that Medicare rules for coverage of a CGM and 
supplies have not been met. Therefore, we decided that the Plan does not have to pre-approve a continuous 
glucose monitor (CGM) and supplies.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve SNF care. 
 
You asked the Plan to pre-approve SNF care. You say that you would benefit from therapy at the SNF to help 
you regain your strength and return to your prior level of function. The Plan denied your request. The Plan says 
the stay is not medically necessary based on SNF criteria. 
 
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 physician reviewer 
found there is no documentation that daily skilled services are required. Although records document you are 
limited functionally, provided records do not document a significant decline in your functional status compared 
to your recent baseline to necessitate daily inpatient skilled therapy 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 care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve SNF care.