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

 
We decided that the Plan does not have to pay for emergency room services provided from  
September 26, 2020, through September 28, 2020. 
 
You asked the Plan to pay for emergency room services. The Plan denied your request. The Plan says non-
hospice related claims for members electing hospice are the responsibility of Original Medicare. 
 
Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice 
services. Original Medicare is responsible for payment for services until the first day of the month after the 
hospice election has been revoked or terminated. 
 
 The enrollee ended Medicare Hospice benefits on September 8, 2020. The services in question were provided 
before the end of that month. Therefore, we decided that the Plan does not have to pay for emergency room 
services provided from September 26, 2020, through September 28, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a domiciliary or rest home visit provided on November 3, 
2021, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for a domiciliary or rest home visit. You say that the assisted living facility is 
responsible to obtain prior authorization for all of their patients, which should also cover for the medical 
treatments provided by this provider. The Plan denied your request. The Plan says this provider is out-of-
network with the Plan, and authorization was not obtained prior to the services being rendered. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
 The requested provider in this case is not a network provider with the Plan. The Plan had network providers 
available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the 
item/service at issue. We found no exception that would require the Plan to pay for these items/services. 
Therefore, we decided that the Plan does not have to pay for a domiciliary or rest home visit provided on 
November 3, 2021, by an out-of-network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Freestyle Libre continuous glucose monitor (CGM). 
 
You asked the Plan to pre-approve a Freestyle Libre CGM. You say that the requested item is a medical 
necessity for the enrollee. The Plan denied your request. The Plan says rules for coverage for CGMs and 
related supplies have 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 the enrollee does not use insulin 
with at least three daily injections. Based on this information, we decided that Medicare rules for coverage of a Freestyle Libre CGM have not been met. Therefore, we decided that the Plan does not have to pre-approve a 
Freestyle Libre continuous glucose monitor (CGM).
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for duplex scan of lower extremity arteries or arterial bypass 
graft (93925) provided on January 13, 2022. 
 
You asked the Plan to pay for the duplex scan. You say that the enrollee had multiple exams on the date in 
question. The Plan denied your request. The Plan says the records only support one instance of 93925 being 
rendered on the date in question. A claim for this service has already been paid; therefore, the submitted claim 
in this case is denied. 
 
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 93925 is duplex scan of lower extremity arteries or arterial bypass grafts; complete bilateral study. 
 
We find that CPT code 93925 is not supported in the medical record. Specifically, one unit of 93925 has been 
paid for the same date. The documentation does not suggest that the enrollee received two complete bilateral 
studies of the lower extremities on the date in question. Based on this information, we decided that Medicare 
rules for coverage of the duplex scan have not been met. Therefore, we decided that the Plan does not have to 
pay for duplex scan of lower extremity arteries or arterial bypass graft (93925) provided on January 13, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for Domiciliary services provided on November 23, 2021 by an 
out-of-network (OON) provider. 
 
You asked the Plan to pay for Domiciliary services. You say that that it isn't your responsibility to obtain prior 
authorization. The Plan denied your request. The Plan says the provider is out-of-network and authorization is 
required prior to an out-of-network visit. 
 
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 Domiciliary services provided on November 23, 
2021 by an out-of-network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a custom left partial hand prosthesis MCP Driver 
(L7499). 
 
You asked the Plan to pre-approve a custom left partial hand prosthesis MCP Driver. You say that the item is 
medically necessary. The Plan denied your request. The Plan says your prosthetist states that a left custom 
prosthetic partial hand prosthesis (MCP Driver) is indicated, but your treating Physician does not provide 
documented specific reasons why you cannot use a left partial hand prosthesis as described in codes L6000, 
L6010, or L6020. The prosthetist/CP/CPO is a vendor, and a vendor has financial interest in the claim outcome. 
Prosthetist's notes are not considered to be part of the medical record per Medicare guidelines and must be 
supported by information from the medical record. While the signed Physician order includes a left custom 
prosthetic partial hand prosthesis (MCP Driver), prescriptions are not considered part of the medical record and 
must be supported by information from the medical record. 
 
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 a custom left partial hand prosthesis 
MCP Driver. Our reviewer says that the clinical documentation in the case file is insufficient to support that the 
left partial hand prosthesis MCP driver is medically reasonable and necessary for you in this case. Our 
physician reviewer found records from suppliers or healthcare professionals with a financial interest in the 
claim outcome are not considered sufficient by themselves for determining that an item is reasonable and 
necessary, and a prescription is not considered to be part of the medical record. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of a custom left partial hand prosthesis MCP Driver have not been met. Therefore, 
we decided that the Plan does not have to pre-approve a custom left partial hand prosthesis MCP Driver 
(L7499).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for targeted genomic sequence analysis panel (CPT code 81455) 
provided on November 19, 2021. 
 
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 covered. 
 
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 services have not been met. Targeted genomic 
sequence analysis panel, code 81455, is non-covered by Medicare. Genetic testing procedures submitted with 
code 81455 are unlikely to impact therapeutic decision-making in the clinical management of the patient and 
will be denied automatically as not medically necessary. Therefore, we decided that the Plan does not have to 
pay for targeted genomic sequence analysis panel (CPT code 81455) provided on November 19, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve foot inserts/orthotics (L3020). 
 
You asked the Plan to pre-approve foot inserts/orthotics. You say that you have damaged nerves between the 
toes and a bone spur on the right foot and you are therefore requesting inserts to go in the shoe to take the 
weight of your heel when you walk. You also say you have had incidents of losing your balance when you try 
to put your foot down, in which almost results to a bad fall. The Plan denied your request. The Plan says you 
have foot pain from plantar fasciitis. You do not wear a brace and you are not diabetic; therefore, this item is 
not a covered benefit. 
 
Medicare rules state that supportive devices for the feet (such as orthotics) are only covered for patients with 
diabetic foot disease or for patients who wear a leg brace. The Plan follows these same rules.   
 
Records show that you do not suffer from diabetic foot disease, and you do not wear a leg brace. Although 
orthotics may be appropriate for you, neither Medicare nor the Plan provides coverage of orthotics for your 
condition. Therefore, we decided that the Plan does not have to pre-approve foot inserts/orthotics (L3020).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for Domiciliary services provided on December 22, 2021 by an 
out-of-network (OON) provider. 
 
You asked the Plan to pay for Domiciliary services. You say that that it isn't your responsibility to obtain prior 
authorization. The Plan denied your request. The Plan says the provider is out-of-network and authorization is 
required prior to an out-of-network visit. 
 
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 Domiciliary services provided on December 22, 
2021 by an out-of-network (OON) provider.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve bilateral L3-L5 radiofrequency ablation (RFA.) 
 
You asked the Plan to pre-approve bilateral L3-L5 RFA. You say that you are in severe pain and the last 
injection only lasted 4 hours. You say that it is hard for you to walk and keep your balance. The Plan denied 
your request. The Plan says the clinical information received does not support that the requested services are 
medically necessary. 
 
The Plan follows Medicare rules. Medicare rules say that RFA services are covered for certain clinical 
indications. 
 
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 bilateral L3-L5 RFA. Our reviewer says 
that the criteria for coverage have not been met. Our physician reviewer found there is no documentation of 
completion of the two (2) required diagnostic MBBs, nor is there any documentation to show that the 
diagnostic studies were successful. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of bilateral L3-L5 RFA have not been met. Therefore, we decided that the Plan 
does not have to pre-approve bilateral L3-L5 radiofrequency ablation (RFA.)
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services rendered on March 23, 2021. 
 
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says the services were not billed correctly. 
 
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 these 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 the laboratory services rendered on March 23, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the observation or inpatient care services coded 99236 
provided on December 10, 2021. 
 
You asked the Plan to pay for the observation or inpatient care services. You say that you would like the plan 
to reconsider their denial. The Plan denied your request. The Plan says the services are a duplicate claim. 
 
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 99236 is Observation or inpatient hospital care, for the 
evaluation and management of a patient including admission and discharge on the same date, which requires 
these 3 key components: A comprehensive history; A comprehensive examination; and Medical decision 
making of high complexity. Counseling and/or coordination of care with other physicians, other qualified 
health care professionals, or agencies are provided consistent with the nature of the problem(s) and the patient's 
and/or family's needs. Usually the presenting problem(s) requiring admission are of high severity. Typically, 55 
minutes are spent at the bedside and on the patient's hospital floor or unit. 
 
 We find that CPT code 99236 is not supported in the medical record. Specifically, the initial observation care 
evaluation and management service (coded 99220) was previously reported for the previous date by another 
provider. Based on this information, we decided that Medicare rules for coverage of the observation or 
inpatient care services have not been met. Therefore, we decided that the Plan does not have to pay for the 
observation or inpatient care services coded 99236 provided on December 10, 2021.
Appeal type: Outpatient Therapies
Decision: Favorable

 
We decided that the Plan has to pre-approve physical therapy provided by a participating provider. 
 
You asked the Plan to pre-approve physical therapy. You say that additional PT sessions are medically 
necessary. The Plan denied your request. The Plan says that PT sessions are no longer medically necessary. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for medically necessary outpatient 
therapy. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve physical therapy. Our reviewer says 
that additional physical therapy is medically necessary. Our physician reviewer found the enrollee has 
improved and continues to improve however still requires physical assistance due for transfers and balance and 
not yet stable for a home exercise plan. Stated goals appear to be reasonable and the enrollee is making 
functional improvement, thus 8 additional physical therapy sessions are medically 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 8 additional physical therapy sessions have been met. Therefore, we decided 
that the Plan has to pre-approve physical therapy provided by a participating provider.  
 
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: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the anti-reflective coating (V2750), prism lenses (V2715), 
trifocal lenses (V2303), progressive lens (V2781), and photochromatic tint (V2744) provided on July 14, 2021. 
 You asked the Plan to pay for the eyewear. You say that you feel all of your vision expenses should be covered 
as you need trifocals to see, prism coated lenses for your double vision, and tinted lenses because you are very 
sensitive to bright light. The Plan denied your request. The Plan says you have exceeded your eyewear benefit. 
 
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 these services up to a $200 limit every year. 
 
We looked at the file and the Plan's rules. The record shows that your $200 routine eyewear allowance was 
exhausted on this July 14, 2021 date of service. Based on this information, we decided that the Plan's rules for 
coverage of the eyewear have not been met. Therefore, we decided that the Plan does not have to pay for the 
anti-reflective coating (V2750), prism lenses (V2715), trifocal lenses (V2303), progressive lens (V2781), and 
photochromatic tint (V2744) provided on July 14, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for subsequent hospital care provided on November 14, 2020. 
 
You asked the Plan to pay for subsequent hospital care. The Plan denied your request. The Plan says the claim 
was received past the allowed 12-month timeframe. 
 
The Plan follows Medicare rules. The rules say that claims for services furnished on or after January 1, 2010, 
must be filed no later than one calendar year after the date of service. 
 
The record shows that a claim for subsequent hospital care was not filed until January 13, 2022. This means 
that more than one calendar year from the date of service had passed before a claim was filed. Therefore, we 
decided that the Plan does not have to pay for subsequent hospital care provided on November 14, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Jetstream cooling and heating blanket. 
 
You asked the Plan to pre-approve a Jetstream cooling and heating blanket. You say that the requested item is a 
medical necessity for you. The Plan denied your request. The Plan says rules for coverage have not been met. 
 
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 Jetstream cooling and heating blanket.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Destruction by neurolytic agent, paravertebral facet 
joint nerve(s), (64635, 64636). 
 
You asked the Plan to pre-approve the facet joint injections. You say that the service is medically necesssary. 
The Plan denied your request. The Plan says there is no evidence of no more than two procedures at the same 
level(s) during a 12- month period of time and that the member had at least 50% relief of facet mediated pain 
for at least 6 months from a previous radiofrequency treatment at the same level(s). 
 
The Plan follows Medicare rules. Medicare rules say that the criteria listed in the Medicare Rules section must 
be met for coverage of this service. 
 
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 facet joint injections. Our reviewer 
says that the service is not medically necessary. Our physician reviewer found the member does not meet LCD 
criteria for coverage of this service. 
 
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 facet joint injections have not been met. Therefore, we decided that the Plan 
does not have to pre-approve the Destruction by neurolytic agent, paravertebral facet joint nerve(s), (64635, 
64636).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the culture services coded 87150 provided on May 25, 2021. 
 
You asked the Plan to pay for the culture services. You say that you would like the plan to reconsider their 
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 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 culture 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 the culture services coded 87150 provided on May 25, 2021.