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

 
We decided that the Plan does not have to pay for procedure code 74176 billed for date of service May 6, 2022. 
 
You asked the Plan to pay for procedure code 74176. You say that you would like the Plan to reconsider their 
denial of payment. The Plan denied your request. The Plan says payment for code 74176 is bundled into 
payment for code 74177.  
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 74176 
is a column II code to column I code 74177. This claim has not been billed with an appropriate modifier to 
bypass the edit. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we 
decided that the Plan does not have to pay for procedure code 74176 billed for date of service May 6, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the subsequent hospital care (99232) provided on May 15, 
2021. 
 
You asked the Plan to pay for the hospital care. You say that the claim was filed timely. The Plan denied your 
request. The Plan says the claim denied correctly. 
 
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 the hospital care was not filed until May 20, 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 the subsequent hospital care (99232) provided on May 15, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for inpatient hospital stay on June 29, 2021, to 
July 14, 2021. 
 
You asked the Plan to waive the coinsurance for inpatient hospital stay. You say that you believe that you 
already paid this amount. The Plan denied your request. The Plan says the cost sharing you are being charged 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 10% 
coinsurance for each Medicare-covered hospital admission/stay. Deductible does apply. Includes inpatient 
acute, inpatient rehabilitation, long-term care hospitals and other types of inpatient hospital services. Inpatient 
hospital care starts the day you are formally admitted to the hospital with a doctors order. The day before you 
are discharged is your last inpatient day. The provider billed in the amount of $34,590 and the allowed amount 
is $28,825.51. The Plan paid $27,466.98. $28,825.51 - $27,466.98 = $1,358.53. Therefore, results in the total 
cost sharing amount of $1,358.53. 
 
You have been asked to pay a $1,358.53 coinsurance for inpatient hospital stay. Inpatient hospital stay falls 
within the Inpatient hospital 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 coinsurance for 
inpatient hospital stay on June 29, 2021, to July 14, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to waive the deductible and copay for the negative pressure wound 
therapy pump, wound care set and canister provided to the enrollee from October 20, 2021, to October 28, 
2021. 
 
You asked the Plan to waive the deductible and copay for these items. You say that you would like this 
reviewed. The Plan denied your request. The Plan says that the enrollee's deductible was not met. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information. The 
enrollees contract with the Plan says that there is $750 deductible which applies to covered medical services. 
The enrollees contract with the Plan clearly says that the enrollee must pay a 20% coinsurance for durable 
medical equipment. 
 
The item or service you asked the Plan to waive the deductible and copay for falls within the covered medical 
services benefit category. The Plan has followed Medicare rules by clearly disclosing in the contract that there 
is $750 deductible which applies to covered medical services. This cost sharing is a contractual obligation that had not been met at the time these items was received on October 20, 2021, to October 28, 2021. The enrollee 
was asked to pay a 20% coinsurance for these items after the deductible was met. These items fall within the 
durable medical equipment benefit category. This means that the enrollee has been asked to pay the correct 
amount based on the contract with the Plan. This cost sharing is a contractual obligation the enrollee agreed to 
pay when she enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the deductible 
and copay for the negative pressure wound therapy pump, wound care set and canister provided to the enrollee 
from October 20, 2021, to October 28, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayments for specialist office and telehealth visits 
provided from March 22, 2022, to April 18, 2022. 
 
You asked the Plan to waive the copayments for the specialist visits. You say that your prescription was sent to 
the wrong pharmacy. The Plan denied your request. The Plan says you have been charged the correct cost 
sharing amount. 
 
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 
copayment for each specialist visit, including telehealth services.  
 
You have been asked to pay a $45 copayment for each of the specialist visits, for a total of $135. The specialist 
visits fall within the Physician/Practitioner Services, Including Doctor's 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 copayments for specialist office and telehealth visits provided from March 
22, 2022, to April 18, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for an ankle brace provided on May 4, 2022. 
 
You asked the Plan to waive the coinsurance for an ankle brace. You say that it would have been cheaper to get 
a brace at your local pharmacy than it was to go through the insurance. The Plan denied your request. The Plan 
says the coinsurance that was applied was 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 20% 
coinsurance for durable medical equipment (DME) and related supplies. The allowed amount of this item was 
$482.66 resulting in a coinsurance amount of $96.53 ($482.66 x 20% = $96.53). 
 
You have been asked to pay a $96.53 coinsurance for an ankle brace. An ankle brace falls within the Durable 
Medical Equipment (DME) and Related 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 
coinsurance for an ankle brace provided on May 4, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve BRCA1 and BRCA2 genetic testing. 
 
You asked the Plan to pre-approve genetic testing. You say that you have digestive issues, and it could help to 
identify issues. The Plan denied your request. The Plan says you do not have a diagnosis of cancer; therefore, 
this test is not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We looked at the file and Medicare rules. The records show that you do not have a diagnosis of cancer. The 
LCD confirms you must have one of the listed diagnosis to be approved for the requested testing. Based on 
this information, we decided that Medicare rules for coverage of genetic testing have not been met. Therefore, 
we decided that the Plan does not have to pre-approve BRCA1 and BRCA2 genetic testing.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the drug testing (G0483 and 81025) provided on August 26, 
2021. 
 
You asked the Plan to pay for the drug testing. You say that you would like the Plan to reconsider their denial 
of payment. The Plan denied your request. The Plan says the records do not support the services billed. 
 
The Plan must follow Medicare rules. Medicare rules say that the provider, supplier, or beneficiary, as 
appropriate, must furnish to the intermediary or carrier sufficient information to determine whether payment is 
due and the amount of payment. 
 
We looked at the file and Medicare rules. Based on this information, we decided that there is insufficient 
information in the record to determine if Medicare rules for coverage of the drug testing (G0483 and 81025) 
provided on August 26, 2021, have been met. The laboratory records provided were cut off on the left side making it impossible to see the full list of medications and drug names tested. Therefore, we decided that the 
Plan does not have to pay for the drug testing (G0483 and 81025) provided on August 26, 2021.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pay for self-administered drugs provided on February 9, 2022, by an 
out-of-network (OON) provider. 
 
You asked the Plan to pay for self-administered drugs. You say that you would like to request reconsideration 
of the denied claim. 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 self-administered drugs provided on February 9, 
2022, by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the office visit and related services provided on May 12, 
2022, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for the office visit and the related services. You say that you are requesting 
reconsideration of the claim. 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 
office visit and the related services. We found no exception that would require the Plan to pay for the office 
visit and the related services. The records provided for review do not show that the services at issue were 
urgent or emergent. Therefore, we decided that the Plan does not have to pay for the office visit and related 
services provided on May 12, 2022, 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 bariatric scale. 
 
You asked the Plan to pre-approve a bariatric scale. You say that the requested item is a necessity for your care. 
The Plan denied your request. The Plan says rules for coverage of durable medical equipment have not been 
met because the requested item does not mainly serve a medical purpose. 
 
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 bariatric scale.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the pneumatic compression device (E0675) and sleeves 
(E0673) provided to the enrollee on February 17, 2022. 
 
You asked the Plan to pay for the pneumatic compression device and sleeve. You say that this was prescribed 
by the enrollee's physician. The Plan denied your request. The Plan says that this is not covered by Medicare. 
 
The Plan follows Medicare rules. The rules state that a PCD that provides intermittent limb compression for the 
purpose of prevention of venous thromboembolism (E0676) is a preventive service. The rules also say that a 
PCD coded as E0675 to treat peripheral arterial disease is not eligible for reimbursement. 
 
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, this item is not a covered benefit of Medicare or the Plan. 
PCDs are not covered for preventions of venous thromboembolism nor for treatment of peripheral artery disease, regardless of how they are billed on the claim. Therefore, we decided that the Plan does not have to 
pay for the pneumatic compression device (E0675) and sleeves (E0673) provided to the enrollee on February 
17, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a limited occlusal adjustment (D9951) provided by an out-of-
network provider on May 2, 2022. 
 
You asked the Plan to pay for a limited occlusal adjustment. You say that you would like the Plan to pay for 
this. The Plan denied your request. The Plan says the rendered dental work is not a covered 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 a limited 
occlusal adjustment (D9951) provided by an out-of-network provider on May 2, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to issue reimbursement for the therapeutic exercises (97110) provided 
on January 30, 2022. 
 
You asked the Plan to issue reimbursement for this service. You say that you are requesting a reconsideration 
of the Plan's denial for payment. The Plan denied your request. The Plan says this service is not a covered 
benefit under your contractual policy or by Medicare. 
 
The Plan must follow Medicare rules. The rules say that the only chiropractic service Medicare covers is 
manual manipulation of the spine to correct a subluxation.  
 
The records show that the service at issue is not manual manipulation of the spine. Therefore, we decided that 
the Plan does not have to issue reimbursement for the therapeutic exercises (97110) provided on January 30, 
2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve 6 office visits to be provided by an out-of-network 
(OON) provider. 
 
You asked the Plan to pre-approve 6 office visits. You say that the requested services are necessary. The Plan 
denied your request. The Plan says there are in-network providers available that can provide the requested 
services. 
 
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. 
 
You are not a network provider with the Plan. The Plan has confirmed there are network providers available 
who can provide the services at issue in this appeal. We found no exception that would require the Plan to pre-
approve these services. Therefore, we decided that the Plan does not have to pre-approve 6 office visits to be 
provided by an out-of-network (OON) provider.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve home health aide (HHA) services. 
 
You asked the Plan to pre-approve HHA services. You say that you need these HHA services because you are 
old and cannot walk on your own. The Plan denied your request. The Plan says your needs appear to be 
primarily custodial in nature and do not meet criteria for HHA services. 
 
The Plan must follow Medicare rules. The rules say that HHA services may be covered if it is medically 
necessary for the enrollee to receive skilled nursing or therapy.  
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of HHA services have not been met. Therefore, we decided that the Plan does not have to pre-approve 
home health aide (HHA) services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a walker with seat attachment replacement. 
 
You asked the Plan to pre-approve a walker with seat attachment replacement. You say that the walker you 
received in 2019 was a straight stand-up walker. The Plan denied your request. The Plan says you do not meet 
the requirements for approval of the requested item. Your records do not show irreparable damage, nor have 
you had a walker with seat attachment longer than 5 years. 
 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 received a walker, folding with wheels, with seat attachment on December 17, 2019. A 
walker, folding with wheels, with seat attachment serves the same purpose as the requested walker with seat 
attachment replacement. The Medicare guidelines confirm that the walker with seat attachment must be at least 
5 years old or unable to be repaired. Therefore, we decided that the Plan does not have to pre-approve a walker 
with seat attachment replacement.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve pembrolizumab (Keytruda). 
 
You asked the Plan to pre-approve Keytruda. You say that the enrollee is a non-surgical patient The Plan 
denied your request. The Plan says the requested use is not approved. 
 
The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for anti-cancer 
drugs if they are medically accepted as safe and effective or appropriate for the particular use.  
 
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 Keytruda. Our physician reviewer 
found that the enrollee has a diagnosis of anaplastic thyroid carcinoma. The record does not indicate the 
presence of stage IVc disease. The FDA has not stated that the requested drug is indicated for the enrollee's 
condition. The Medicare approved cancer drug compendia do not contain a supportive citation for the use of 
the requested drug in the enrollee's clinical situation. No literature from Medicare approved cancer journals 
were submitted for review. The elements of the coverage criteria are not satisfied. Therefore, the requested 
service cannot be recommended 
 We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Keytruda have not been met. Therefore, we decided that the Plan does not have 
to pre-approve pembrolizumab (Keytruda).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for medical services provided on September 27, 2021, and 
September 28, 2021. 
 
You asked the Plan to pay for the medical services. You say that the Plan has recouped payment for this service 
incorrectly. The Plan denied your request. The Plan says the patient was enrolled in hospice on the dates of 
service in question. 
 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 medical services provided on September 27, 2021, and 
September 28, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve sensors for use with interstitial continuous glucose 
monitoring (A9276) and transmitter, external for use with interstitial continuous glucose monitoring (A9277). 
 
You asked the Plan to pre-approve these services. You say that these are medically necessary for you. The Plan 
denied your request. The Plan says that this is not covered by the Plan or Medicare. 
 
The Plan must follow Medicare rules. Medicare rules say that CGM devices covered by Medicare under the 
DME benefit are defined as therapeutic CGMs and codes A9276 and A9277 are used to describe the supplies 
used with a non-therapeutic CGM. 
 
We looked at the file and Medicare rules. Based on this information, we decided that you are requesting 
supplies for a non-therapeutic CGM. Medicare will only cover therapeutic continuous glucose monitors and 
supplies. Therefore, we decided that the Plan does not have to pre-approve sensors for use with interstitial 
continuous glucose monitoring (A9276) and transmitter, external for use with interstitial continuous glucose 
monitoring (A9277).