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

 
We decided that the Plan does not have to pre-approve the ROMTech PortableConnect. 
 
You asked the Plan to pre-approve the ROMTech PortableConnect. You say that this device helps patients to 
increase their range of motion after any type of knee surgery. The Plan denied your request. The Plan says this 
device is not approved by the enrollee's plan because it is still being studied to see if it is as good or better than 
the standard rehabilitation therapy after knee replacement surgery. 
 
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 ROMTech PortableConnect. Our 
reviewer says that the requested items/services are not considered medically reasonable and necessary in this 
case. Our physician reviewer found the enrollee is not enrolled in a clinical trial per the appeal letter. There is 
limited published, large-scale, long-term peer-reviewed literature that shows the requested item to be an 
effective and/or safe. The review has determined that ROMTech PortableConnect is not medically reasonable 
or necessary. 
 
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 ROMTech PortableConnect have not been met. Therefore, we decided that 
the Plan does not have to pre-approve the ROMTech PortableConnect.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve FreeStyle Neo diabetic test strips. 
 
You asked the Plan to pre-approve FreeStyle Neo diabetic test strips. You say that you have tremors which do 
not allow you to use other types of test strips. The Plan denied your request. The Plan says there are covered 
diabetic supplies available through a retail pharmacy. 
 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 rules also say 
that Plans may specify brands and manufacturers as preferred and limit CME coverage to only those preferred 
brands and manufacturers as long as the enrollee retains access to all medically necessary items.  
 
The requested diabetic supplies in this case are not one the Plan's preferred brands. The Plan has diabetic 
testing strips available through a retail pharmacy made by their preferred brands, that can meet the enrollee's 
medical needs. There was no evidence provided that demonstrated the Plan's preferred brand testing strips 
would be ineffective or inadequate in meeting the enrollee's medical needs. We found no exception that would 
require the Plan to pre-approve diabetic testing strips from a non-preferred brand. Therefore, we decided that 
the Plan does not have to pre-approve FreeStyle Neo diabetic test strips.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve 2 skilled nursing home health visits (G0299). 
 
You asked the Plan to pre-approve 2 skilled nursing home health visits. You say that home health skilled 
nursing care continues to be medically necessary. The Plan denied your request. The Plan says the requested 
services are no longer necessary. 
 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 2 skilled nursing home health visits. 
Our reviewer says that continued skilled nursing home health care is not medically reasonable and necessary. 
Our physician reviewer found based on the medical records provided there is no documentation that further 
skilled nursing services are required to effectively provide treatment, care, and/or services in order to improve 
your condition, or to establish/perform a maintenance program to maintain your condition and/or prevent 
deterioration. Provided records were reviewed; records do not document any acute or unstable medical 
conditions or changes in medication or treatment which would necessitate any further skilled nursing visits 
beyond what have already been approved. No medical notes from your treating physician are provided 
documenting an order or need for additional skilled nursing 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 2 skilled nursing home health visits have not been met. Therefore, we decided 
that the Plan does not have to pre-approve 2 skilled nursing home health visits (G0299).
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the occupational therapy services rendered on August 11, 
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 procedure code 97530 is not 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 97530 is therapeutic activities, direct (one-on-one) 
patient contact (use of dynamic activities to improve functional performance), each 15 minutes. 
 
We find that CPT code 97530 is not supported in the medical record. Specifically, the records show that the 
services were performed in the home setting and there is a more appropriate code for these services. Based on 
this information, we decided that Medicare rules for coverage of these services have not been met. Therefore, we decided that the Plan does not have to pay for the occupational therapy services rendered on August 11, 
2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory service (CPT code 0242U) provided on June 
3, 2021. 
 
You asked the Plan to pay for the laboratory service. You say that the claim should be paid. The Plan denied 
your request. The Plan says the service is not covered as billed. 
 
The Plan must follow Medicare rules. We looked at the file and Medicare rules. Based on this information, we 
decided that Medicare rules for coverage of the laboratory service have not been met. CPT code 0242U (1 
Unit) remains not supported. The place of service on the CMS-1500 form line 24B must reflect the location of 
the patient when the specimen was obtained. The submitted claim form indicates the laboratory specimen was 
obtained in a laboratory, POS 81; however, the submitted medical documentation and/or claim history indicates 
that the specimen was obtained in an office setting POS 11; therefore, the billed code cannot be verified. It is 
noted multiple attempts were made to obtain additional information from the provider. Therefore, we decided 
that the Plan does not have to pay for the laboratory service (CPT code 0242U) provided on June 3, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the office visit provided on November 4, 2021, by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for the office visit. You say that the service is medically necessary, and the service is 
payable. 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 the office visit provided on November 4, 2021, by an out-of-
network (OON) provider.
Appeal type: Home Health
Decision: Favorable

 
We decided that the Plan has to pay for the home health services provided from May 12. 2021, through June 3, 
2021. 
 
You asked the Plan to pay for the home health services. You say that the claim should be paid. The Plan denied 
your request. The Plan says that PDGM code is needed to reprocess this home health claim. 
 
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. 
 
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 showed a claim billed with a valid HIPPS code, and the only thing the 
Plan said is that it is not valid; therefore, the plan failed to give a valid rationale. Therefore, we decided that the 
Plan has to pay for the home health services provided from May 12. 2021, through June 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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the cardiovascular office visit on the 
November 5, 2021 
 
You asked the Plan to waive the copayment for the office visit. You say that the provider charging the copay 
only saw you for about 5 minutes. The Plan denied your request. The Plan says the copayment applied is 
correct. 
 
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 $45 
copay for each Medicare-covered visit with a specialist.  
 
 
 You have been asked to pay a $45 copay for the office visit. The office visit falls within the 
Physician/Practitioner services, including doctors office visits benefit category. This means that you have 
been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual 
obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have 
to waive the copayment for the cardiovascular office visit on the November 5, 2021
Appeal type: Outpatient Therapies
Decision: Partially Favorable

 
We decided that the Plan has to waive the copayments for therapeutic activities provided from December 7, 
2020, to December 30, 2020. We decided that the Plan does not have to waive the copayments for therapeutic 
activities provided from January 4, 2021, to February 5, 2021.  
 
You asked the Plan to waive the copayments for therapeutic activities. You say that you should not have to pay 
the copayments because of late billing from the provider office. The Plan says that you have been charged the 
correct cost sharing amount. The Plan processed all the claims at the in-network rate. 
 
We decided that the Plan has to waive the copayments for therapeutic activities provided from 
December 7, 2020, to December 30, 2020.  
 
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. 
 
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 has not provided the complete Evidence of Coverage for 2020. We are 
unable to determine if cost sharing applies without the correct benefit information. Therefore, we decided that 
the Plan has to waive the copayments for therapeutic activities provided from December 7, 2020, to December 
30, 2020. 
 
We also decided that the Plan does not have to waive the copayments for therapeutic activities provided 
from January 4, 2021, to February 5, 2021. 
 
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 $30 
copayment for each in-network physical therapy visit. 
 
You have been asked to pay $360, which is a $30 for each therapeutic activity from January 4, 2021, to 
February 5, 2021 ($30 copayment x 12 visits = $360). Therapeutic activities 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 copayments for therapeutic 
activities provided from January 4, 2021, to February 5, 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. 
 
Your complaint about the late billing from the provider is not a valid appeal for medical coverage. This part of 
your complaint is a grievance that must be answered by the Plan. Medicare does not permit us to make a 
decision about these types of complaints.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the total thyroid lobectomy, unilateral; with or without 
isthmusectomy (CPT code 60220) provided on April 27, 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 surgical procedure is included in the 90-day global period. 
 
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 surgical procedure is included in the 90-day global period. Surgery procedure 60500 has a global value of 
090 on the CMS National Physician Fee Schedule (NPFS) Relative Value (RVU) file. This is a major 
procedure that has a global surgery period of 90 days. Procedure 60220 billed on date of service April 27, 
2021, is included within the global surgery package of procedure 60500 billed on date of service March 16, 
2021. 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 total thyroid lobectomy, unilateral; with or 
without isthmusectomy (CPT code 60220) provided on April 27, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the diagnostic casts (D0470) provided on November 8, 2021. 
 
You asked the Plan to pay for diagnostic dental casts. You say that this service is medically necessary. The 
Plan denied your request. The Plan says this service is not covered by your dental benefit. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the 
diagnostic casts (D0470) provided on November 8, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services (CPT code(s): 81005 and 85025) 
provided from July 2, 2020, through July 6, 2020. 
 
You asked the Plan to pay for the laboratory services. You say that the claim should be paid. The Plan denied 
your request. The Plan says the services are not supported by the records. 
 
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 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 laboratory services. Our reviewer found the 
documentation submitted did not include documentation of urinalysis; qualitative or semiquantitative, except 
immunoassays for the billed date of service; therefore, the billed service cannot be verified. The documentation 
submitted did not include documentation of Blood count; complete (CBC), automated (Hgb, Hct, RBC, WBC 
and platelet count) and automated differential WBC count; therefore, the billed service cannot be verified. The 
review has determined that the services are not supported by the medical records. 
 
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 laboratory services have not been met. Therefore, we decided that the Plan 
does not have to pay for the laboratory services (CPT code(s): 81005 and 85025) provided from July 2, 2020, 
through July 6, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the vitrectomy seated support equipment, fuel surcharge and 
sales tax provided September 10, 2021 to September 20, 2021. 
 
You asked the Plan to pay for the vitrectomy seated support equipment. You say that your doctor provided the 
written order for the medically necessary equipment for postoperative recovery during the 24/7 face down 
positioning. The Plan denied your request. The Plan says services were rendered by a provider who is not 
certified with Medicare. 
 
The Plan must follow Medicare rules. The rules say that Medicare payment cannot be made to a provider that is 
not enrolled in the Medicare program. 
 
 
 
 Review of the file and Medicare records indicates that the provider at issue is not enrolled in the Medicare 
program. Therefore, we decided that the Plan does not have to pay for the vitrectomy seated support 
equipment, fuel surcharge and sales tax provided September 10, 2021 to September 20, 2021.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for psychotherapy and the office visit provided on August 10, 
2021, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for the psychotherapy and the office visit. You say that the services do not require 
authorization when billed by this provider. 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. 
Therefore, we decided that the Plan does not have to pay for psychotherapy and the office visit provided on 
August 10, 2021, by an out-of-network (OON) provider.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayments for radiation therapy services provided to the 
enrollee from June 21, 2021, to August 11, 2021. 
 
You asked the Plan to waive the copayments for the services. You say that if you had known this amount, you 
would have used other methods or resources of payments. The Plan denied your request. The Plan says the 
copayments were applied correctly. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $60 
copayment for radiation therapy.  
 
You have been asked to pay a $60 copayment for each of the radiation therapy visits at issue in this case, for a 
total of $1,920. The services fall within the radiation therapy 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 copayments for radiation therapy services provided to the enrollee from June 21, 2021, to August 
11, 2021.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for psychotherapy (90832) provided on June 7, 2021, by an out-
of-network (OON) provider. 
 
You asked the Plan to pay for psychotherapy. You say that you have rendered treatment to the patient in good 
faith that the service would get reimbursed, and the service was provided with no adequate time frame to obtain 
authorization for the service. The Plan denied your request. The Plan says the services are not authorized 
because this provider is a non-network provider who does not work with the Plan, and the member was referred 
by a provider, who also does not work with the Plan.  The Plan also says that the member's primary care physician (PCP) did not refer for services, and no medical 
necessity for an out-of-network provider, such as an urgent or emergency situation, has been documented. 
 
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 psychotherapy (90832) provided on June 7, 2021, 
by an out-of-network (OON) provider.