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

 
We decided that the Plan does not have to pre-approve the ForeseeHome eye monitor device. 
 
You asked the Plan to pre-approve the ForeseeHome eye monitor device. You say that this is medically 
reasonable and necessary for the enrollee's condition. The Plan denied your request. The Plan says there is a 
lack of evidence to support the use of device over traditional monitoring of macular degeneration. 
 
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 ForeseeHome eye monitor device. 
Our reviewer says that the requested items/services are not considered medically reasonable and necessary in 
this case. Our physician reviewer found based on the medical records provided and the current peer-reviewed 
medical literature there is no documentation that the ForeseeHome eye monitor device at issue in this case 
meets Medicare criteria. Provided records and review of the current peer-reviewed medical literature do not 
document efficacy and necessity of the device to improve long term outcomes over traditional monitoring and 
treatment for age-related macular degeneration. 
 
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 ForeseeHome eye monitor device have not been met. Therefore, we decided 
that the Plan does not have to pre-approve the ForeseeHome eye monitor device.
Appeal type: Hospice
Decision: Unfavorable

 
We decided that the Plan does not have to pay for hospital discharge day management services provided on 
December 17, 2021. 
 
You asked the Plan to pay for hospital discharge day management services. The Plan denied your request. The 
Plan says original Medicare is responsible for payment. 
 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 hospital discharge day management services provided on 
December 17, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for medical eye exam provided on April 18, 
2022. 
 
You asked the Plan to waive the copayment for medical eye exam. You say that this was supposed to be a 
routine eye exam. The Plan denied your request. The Plan says since you have blurry vision and cataracts this 
was a medical exam. 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 $40 
copayment for Medicare-covered eye exams to diagnose and treat diseases and conditions of the eyes.  
 
You have been asked to pay $40 copayment for medical eye exam. Medical eye exams fall within the Vision 
Care 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 medical eye exam provided on 
April 18, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve coverage of a mattress. 
 
You asked the Plan to pre-approve a mattress. You say that you need support for a pinched nerve. You would 
like to purchase a mattress from a local store in your area. The Plan denied your request. The Plan says 
Medicare may only cover a mattress where a hospital bed is medically necessary or when there is evidence of 
pressure ulcers. The Plan also says a mattress does not meet the definition of DME (is not primarily used for a 
medical purpose) and is also not considered medically necessary by Medicare or the Plan. 
 
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 coverage of a mattress.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for initial nursing facility care provided on February 7, 2022, by 
an out-of-network (OON) provider. 
 
You asked the Plan to pay for initial nursing facility care. You say that this was medically necessary. The Plan 
denied your request. The Plan says services from non-participating providers are not covered unless 
preauthorized. 
 
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 initial nursing facility care provided on February 
7, 2022, by an out-of-network (OON) provider.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 20930 and 20936 billed for date of service 
January 6, 2022. 
 You asked the Plan to pay for procedure codes 20930 and 20936. You say that you have provided medical 
records to support payment. The Plan denied your request. The Plan says procedure codes 20930 and 20936 are 
considered bundled and not separately payable. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate procedure code. 
 
We find that procedure codes 20930 and 20936 have a status indicator of B on the Physician Fee Schedule. 
This means that procedure codes 20930 and 20936 are not separately payable. Based on this information, we 
decided that Medicare rules for coverage of procedure codes 20930 and 20936 have not been met. Therefore, 
we decided that the Plan does not have to pay for procedure codes 20930 and 20936 billed for date of service 
January 6, 2022.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the ambulance services provided on 
February 25, 2022, and February 28, 2022. 
 
You asked the Plan to waive the copayment for the ambulance services. You say that these charges should be 
removed, you shouldn't be charged for services that the rehabilitation center could not do. The Plan denied your 
request. The Plan says you were charged this cost sharing 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 $125 
copayment for each ambulance trip. You had two ambulance trip(s). The Plan charged you $228.04 for these 
services. 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 ambulance services provided on February 
25, 2022, and February 28, 2022.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for wheelchair van transportation provided on April 27, 2022. 
 
You asked the Plan to pay for wheelchair van transportation. You say that this service should be covered. The 
Plan denied your request. The Plan says the service at issue is not a covered benefit. 
 
The Plan must follow Medicare rules. The rules say that Medicare does not pay for wheelchair van transport 
services.  
 
The services you have asked the Plan to pay for are wheelchair van transport services. Therefore, we decided 
that the Plan does not have to pay for wheelchair van transportation provided on April 27, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a portable oxygen concentrator (E1392). 
 
You asked the Plan to pre-approve a portable oxygen concentrator. You say that you need an oxygen device 
daily. The device provided by the Plan is too heavy. The Plan denied your request. The Plan says you do not 
meet coverage criteria for a portable oxygen concentrator. You currently have the standard item that meets your 
medical needs. You have not failed the standard equipment. You can request additional testing to determine if 
needs have changed. 
 
The Plan must follow Medicare rules. The rules say Medicare covers DME only when it is reasonable and 
necessary. If DME serves the same purpose as equipment already available to an enrollee, it is not considered 
reasonable and necessary. 
 
The file shows that you have a stationary oxygen concentrator and a Homefill unit with D-tanks for portability. 
A stationary oxygen concentrator serves the same purpose as a portable oxygen concentrator. Therefore, we 
decided that the Plan does not have to pre-approve a portable oxygen concentrator (E1392).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code A4220 billed for date of service November 
17, 2021. 
 
You asked the Plan to pay for procedure code A4220. You say that this should be covered The Plan denied 
your request. The Plan says procedure code A4220 is considered bundled and not separately payable. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate procedure code.  
We find that procedure code A4220 has a status indicator of P on the Physician Fee Schedule. This means that 
procedure code A4220 is not separately payable. Based on this information, we decided that Medicare rules for 
coverage of procedure code A4220 have not been met. Therefore, we decided that the Plan does not have to 
pay for procedure code A4220 billed for date of service November 17, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services coded 88361, 88312, 88305, and 
88112 provided on February 10, 2022. 
 
You asked the Plan to pay for the laboratory 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. 
 
We find that CPT codes 88361, 88312, 88305, and 88112 are not supported in the medical record. Specifically, 
these codes have a professional component/technical component of 1. These services were billed with a place 
of service 22 (on campus-outpatient hospital). The professional interpretation was furnished in the same 
payment locality from where the technical component was furnished. We find that the Medicare rule for 
payment of this claim has not been met as the professional interpretation of a diagnostic test must be separately 
billed with modifier  26 by the interpreting physician. 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 coded 88361, 88312, 88305, and 88112 provided on February 10, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for genetic testing (81455) provided June 7, 2021. 
 
You asked the Plan to pay for the genetic testing. You say that this service was medically necessary. The Plan 
denied your request. The Plan says coverage criteria has not been met. 
 
The Plan must follow Medicare rules. Medicare rules say that panels that include the FANCC genes are non-
covered.  
 
We looked at the file and Medicare rules. This test is non-covered under the Local Coverage Article. Records 
provided do not show the enrollee has a cancer diagnosis as required by National Coverage Determination: 
Next Generation Sequencing (90.2). Based on this information, we decided that Medicare rules for coverage of 
the genetic testing have not been met. Therefore, we decided that the Plan does not have to pay for genetic 
testing (81455) provided June 7, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a home visit and a brief emotional/behavioral assessment 
provided on April 18, 2022, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for a home visit and a brief emotional/behavioral assessment. You say that you are 
appealing with supporting records. The Plan denied your request. The Plan says this provider is not a network 
provider with the Plan. The Plan also says that these services were not referred by a network provider or 
rendered in a participating facility. The Plan also says that they have also determined that these services are not 
urgent or emergent, nor were they approved in advance. 
 
 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 home visit and a brief emotional/behavioral 
assessment provided on April 18, 2022, by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pay for code 99223 billed for date of service May 31, 2021. 
 
You asked the Plan to pay for code 99223. You say that you have provided medical records to support 
payment. The Plan denied your request. The Plan says that this code is not supported in the medical records. 
 
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. Specifically, the Plan's sole rationale for denial is that the medical records do not 
support the billing of code 99223.  Both your appeal letter and the case narrative form that the Plan provided to 
us indicate that medical records were provided and reviewed.  However, the Plan failed to submit any medical 
records in the case file that it forwarded to us.  Without these medical records (that the Plan confirmed that they 
had), the Plan's denial rationale cannot be supported. Therefore, we decided that the Plan has to pay for code 
99223 billed for date of service May 31, 2021.  
 
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again 
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake 
and/or send us the new information. This does not happen often. If we decide to open the case again, we will 
send you a letter.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for diagnostic mammogram provided on April 
29, 2022. 
 
You asked the Plan to waive the copayment for diagnostic mammogram. You say that you didn't have to pay a 
copayment in the past and you shouldn't now. 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 $20 
copayment for each basic imaging service (e.g., general x-rays or ultrasound).  
 
You have been asked to pay $20 copayment for diagnostic mammogram. Diagnostic mammograms fall within 
the Outpatient Diagnostic Tests and Therapeutic Services and Supplies 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 diagnostic mammogram provided on April 29, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a pneumatic compression device and appliances (E0652, 
E0656, E0667). 
 
You asked the Plan to pre-approve a pneumatic compression device and appliances. You say that you 
previously submitted clearly prescribed and appropriate finding, notes, and medical records to support 
Medicare guidelines for approval of service. The Plan denied your request. The Plan says coverage criteria has 
not been met. 
 
The Plan follows Medicare rules. The rules state that a PCD coded as E0652 is covered for the treatment of 
lymphedema extending onto the chest, trunk and/or abdomen after a four-week trial of conservative therapy 
demonstrating failed response to treatment with an E0650 or E0651. At least four weeks of regular, daily, 
multiple-hour home usage of the E0650 or E0651 is required. 
 
We looked at the file and Medicare rules. Based on this information we decided that Medicare rules for 
coverage of the PCD have not been met. Specifically, the record does not show that the enrollee had at least 
four weeks of regular, daily, multiple-hour home usage of the E0650 or E0651 after careful, in-person fitting, 
training and supervision by a technician who is skilled in and who regularly and successfully uses the appliance 
provided. Therefore, we decided that the Plan does not have to pre-approve a pneumatic compression device 
and appliances (E0652, E0656, E0667).
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Prolia (J0897). 
 
You asked the Plan to pre-approve Prolia. You say that the requested drug is medically necessary for the 
enrollee's diagnosis. The Plan denied your request. The Plan says the enrollee has not tried and failed the 
preferred drug, Zoledronic acid. 
 Medicare covers Part B medications when they are reasonable and necessary but allows health plans to 
implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain 
Part B medications. 
 
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 Prolia. Our reviewer says that the step 
therapy criteria have not been met. Our physician reviewer found the provided documentation does not indicate 
there has been a trial and failure of zoledronic acid. The reviewer found that the documentation does not 
support that zoledronic acid would likely be less effective, and/or would likely have adverse effects for the 
enrollee in this case. Therefore, the reviewer found that the step therapy criteria have not been met. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Prolia have not been met. Therefore, we decided that the Plan does not have to 
pre-approve Prolia (J0897).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for specialist office visit provided on April 13, 
2022. 
 
You asked the Plan to waive the copayment for specialist office visit. You say that since you were given wrong 
information on your bone scan it should be covered. 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 $20 
copayment for each specialist office visit.  
 
You have been asked to pay $20 copayment for specialist office visit. Specialist office visits fall 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 specialist office visit provided on April 13, 2022.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home health services received from January 1, 2022, to 
January 6, 2022. 
 
You asked the Plan to pay for the home health services. You say that you received unclear and inadequate 
explanations. You also say that you would like this claim to be reviewed for payment. The Plan denied your 
request. The Plan says the services received are not a covered benefit from this provider. 
 
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 home health services received from 
January 1, 2022, to January 6, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for dance classes. 
 
You asked the Plan to pay for dance classes. You say that this should be covered. The Plan denied your request. 
The Plan says dance classes are not a covered benefit under the wellness allowance. 
 
The rules say that Medicare does not cover gym benefits. However, the Plan offers a benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. The Plan covers gym benefits 
only for membership in a qualified health club or fitness facility, covered instructional fitness classes, 
participation in wellness programs, memory fitness activities, acupuncture and/or covered nutritional 
counseling sessions with a licensed nutritional counselor or registered dietician. 
 
The Plans rules for coverage of gym benefits have not been met because dance classes are not a covered 
benefit under the wellness allowance. Therefore, we decided that the Plan does not have to pay for dance 
classes.