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

 
We decided that the Plan does not have to pay for procedure code 70450 billed for date of service May 25, 
2022. 
 
You asked the Plan to pay for procedure code 70450. You say that you would like this claim reprocessed and 
approved for payment. The Plan denied your request. The Plan says payment for code 70450 is bundled into 
payment for code 70496. 
 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 70450 
is a column II code to column I code 70496. 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 70450 billed for date of service May 25, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a continuous glucose monitor (K0553) provided on February 
2, 2022. 
 
You asked the Plan to pay for the continuous glucose monitor. You say that the services were medically 
necessary. The Plan denied your request. The Plan says the records do not support the billed servce. 
 
The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when there are both a 
physician order and proof of delivery.  
 
The record does not contain relevant medical records which support medical necessity for the supplies provided 
in this case. The records provided do not show the provider discussed the need for this equipment. The records provided do not show the enrollee uses insulin with 3 or more injections per day. The record shows that the 
Plan made several attempts to obtain the necessary documentation without success. Therefore, we decided that 
the Plan does not have to pay for a continuous glucose monitor (K0553) provided on February 2, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an eye refraction provided on March 11, 2022. 
 
You asked the Plan to pay for an eye refraction. The Plan denied your request. The Plan says the claim was 
submitted with a primary diagnosis that is a non-routine diagnosis code H33.322, which is described as Round 
Hole, Left Eye. The Plan does not cover refraction services when the eye exam is for a non-routine vision 
diagnosis. 
 
The Plan must follow Medicare rules. Medicare does not pay for procedures performed in the course of any eye 
exam to determine the refractive state of the eyes. Refractive procedures are not covered even when done in 
connection with otherwise covered diagnosis or treatment of illness or injury. 
 
We looked at the file and the Medicare rules. Medicare does not pay for procedures performed in the course of 
any eye exam to determine the refractive state of the eyes. Therefore, we decided that the Plan does not have to 
pay for an eye refraction provided on March 11, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve True Metrix glucose test strips. 
 
You asked the Plan to pre-approve True Metrix glucose test strips. You say that the requested test strips are 
medically necessary. The Plan denied your request. The Plan says the requested test strips are not a preferred 
brand product with the enrollee's plan. 
 
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 the requested test strips are not a preferred 
brand product. The EOC confirms that the plan will cover a non-preferred test strip if the provider gives a 
reason for medical necessity. The records also show the provider did not submit a documentation showing 
medical necessity for a non-preferred brand of test strips. Based on this information, we decided that Medicare 
rules for coverage of True Metrix glucose test strips have not been met. Therefore, we decided that the Plan 
does not have to pre-approve True Metrix glucose test strips.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve incontinence supplies. 
 
You asked the Plan to pre-approve incontinence supplies. You say that you cannot afford the incontinence 
supplies. You also say it is not your fault that you have this condition which requires these supplies. The Plan 
denied your request. The Plan says incontinence supplies are not a covered benefit under your plan. 
 
The Plan covers all items that Medicare covers. Medicare rules state that incontinence supplies are not covered 
because they are hygienic items that are non-reusable.  
 
While incontinence supplies may be appropriate in this case, neither the Plan nor Medicare offers coverage of 
these items. Therefore, we decided that the Plan does not have to pre-approve incontinence supplies.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a pneumatic compression device (E0652) and garments 
(E0667, E0656). 
 
You asked the Plan to pre-approve a pneumatic compression device and garments. You say that request 
reconsideration of the decision based on the included clinical documents demonstrating that the enrollee suffers 
from persistent lymphedema and requires the Flexitouch device to treat both RLE and truncal swelling. The 
Plan denied your request. The Plan says the enrollee does not meet the LCD criteria for an advanced 
lymphedema pump as there is no failed four-week trial of a basic pneumatic compression device of either 
E0650 or E0651. 
 
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 
(E0652) and garments (E0667, E0656).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a pneumatic compression device (E0652), a segmental 
pneumatic appliance for use with pneumatic compressor, trunk (E0656) and a segmental pneumatic appliance 
for use with pneumatic compressor, full leg (E0667). 
 
You asked the Plan to pre-approve a pneumatic compression device and garments. You say that you disagree 
with the denial. The Plan denied your request. The Plan says before this type of pump can be approved, we 
need to know that the enrollee has swelling that extends to her chest or abdomen that has not responded to 
standard treatments. The enrollee needs to have failed 4 weeks of a different kind of basic pump (E0650 or 
E0651). The additional information sent does not show that the enrollee tried a basic pump for 4 weeks. There 
is also no documentation that she has any swelling in her trunk or abdomen. 
 
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 
(E0652), a segmental pneumatic appliance for use with pneumatic compressor, trunk (E0656) and a segmental 
pneumatic appliance for use with pneumatic compressor, full leg (E0667).
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve psychotherapy services (90832) at an article 16 clinic. 
 
You asked the Plan to pre-approve the psychotherapy services at an article 16 clinic. You say that this service 
is medically necessary. The Plan denied your request. The Plan says this service is covered under Medicaid and 
is not a Medicare-covered benefit. 
 
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. The plan's Evidence of Coverage states this service may be eligible for coverage through the 
enrollee's Fee-For-Service Medicaid coverage. Therefore, we decided that the Plan does not have to pre-
approve psychotherapy services (90832) at an article 16 clinic.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for inpatient rehabilitation provided on April 
14, 2022, to April 21, 2022. 
 
You asked the Plan to waive the copayment for inpatient rehabilitation. You say that you should not be 
responsible to pay this. The Plan denied your request. The Plan says this cost sharing was charged 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 $1,875 
copayment for inpatient hospital care. 
 
You have been asked to pay a $1,875 copayment for inpatient rehabilitation. This item/service 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 copayment for inpatient 
rehabilitation provided on April 14, 2022, to April 21, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for federally qualified health center (FQHC) visit provided on 
June 14, 2022, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for FQHC visit. You say that you are appealing the claim payment denial. The Plan 
denied your request. The Plan says the services were provided out-of-network and were not approved in 
advanced. 
  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 federally qualified health center (FQHC) visit 
provided on June 14, 2022, by an out-of-network (OON) provider.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for ambulance transportation (A0428) 
provided on April 6, 2022. 
 
You asked the Plan to waive the copayment for the ambulance transportation. You say that this service should 
be covered. The Plan denied your request. The Plan says this cost sharing was charged 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 $325 
copayment for Ambulance Transportation.  
 
You have been asked to pay a $316.81 copayment for the ambulance transportation. Since your maximum out-
of-pocket expense was reached, the copayment you are asked to pay is less than the $325 listed in the Evidence 
of Coverage. 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 ambulance transportation (A0428) provided 
on April 6, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the low dose computed tomography (LDCT) scan for lung 
cancer screening (71271) provided on June 8, 2022. 
 You asked the Plan to pay for the LDCT scan. You say that the enrollee had a computerized axial tomography 
scan done on June 8, 2022, because their doctor recommended it. You also say that you would like to appeal 
this service. The Plan denied your request. The Plan says the maximum benefit for this service has been 
exceeded. 
 
The Plan must follow Medicare rules. The rules say that Medicare covers one annual LDCT scan for lung 
cancer screening for enrollees who meet all the criteria described in the Medicare rules section of this letter.  
 
We reviewed the file and the Medicare rules. We find that the enrollee received a LDCT for lung cancer 
screening on February 28, 2022, and their LDCT scan benefit has been exhausted. The record also shows that 
there is no written order for an additional LDCT lung cancer screening. Therefore, we decided that the Plan 
does not have to pay for the low dose computed tomography (LDCT) scan for lung cancer screening (71271) 
provided on June 8, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a Group 2 heavy-duty power wheelchair (K0825). 
 
You asked the Plan to pre-approve a heavy-duty power wheelchair. You say that the requested item is a 
medical necessity for you. The Plan denied your request. The Plan says rules for coverage for durable medical 
equipment have not been met. 
 
The Plan must follow Medicare rules. Medicare rules say that, in the absence of program instructions, the 
reasonable useful lifetime of equipment can in no case be less than 5 years. Computation of the useful lifetime 
is based on when the equipment is delivered to the enrollee, not the age of the equipment. 
 
We looked at the file and Medicare rules. In this case, you are requesting a replacement for a power wheelchair 
received by you in January 2021. Therefore, the requested replacement is for an item that has not outlasted its 
reasonable useful lifetime. The case record does not document that replacement is necessary due to a change in 
your condition. Based on this information, we decided that Medicare rules for coverage of a replacement power 
wheelchair have not been met. Therefore, we decided that the Plan does not have to pre-approve a Group 2 
heavy-duty power wheelchair (K0825).
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the computed tomography (CT) of the abdomen and pelvis 
(74178) and low osmolar contrast material (Q9967) provided on May 27, 2022, by an out-of-network (OON) 
provider. 
 
You asked the Plan to pay for the CT of the abdomen and pelvis and low osmolar contrast material. You say 
that you provided a service and should be compensated. The Plan denied your request. The Plan says these 
services were rendered by an out-of-network (OON) provider. The Plan also says that there is no authorization 
on file. 
 
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 the computed tomography (CT) of the abdomen 
and pelvis (74178) and low osmolar contrast material (Q9967) provided on May 27, 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 Dexcom G6 continuous glucose monitor (CGM). 
 
You asked the Plan to pre-approve a Dexcom G6 CGM. You say that this would bring better health results. The 
Plan denied your request. The Plan says the requirements for coverage 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 you do not use insulin with at least 
three daily injections. Based on this information, we decided that Medicare rules for coverage of a Dexcom G6 CGM have not been met. Therefore, we decided that the Plan does not have to pre-approve a Dexcom G6 
continuous glucose monitor (CGM).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a remote monitoring physiologic device provided on May 6, 
2022, by an OON provider. 
 
You asked the Plan to pay for a remote monitoring physiologic device. You say that this procedure was done in 
reference to an annual physical and would like the decision to be reconsidered. The Plan denied your request. 
The Plan says the out-of-network services were not authorized. 
 
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 remote monitoring physiologic device provided 
on May 6, 2022, by an OON provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a grab bar. 
 
You asked the Plan to pay for a grab bar. You say that you need the grab bar because you have had a knee 
replacement, making it difficult to get in and out of the tub for bathing. You also have osteoporosis which 
would make a fall dangerous. The Plan denied your request. The Plan says Medicare does not cover grab bars 
as they are not considered medical equipment. However, you may get up to $75 toward a grab bar through your 
OTC benefit. 
 
The Plan covers all items that Medicare covers. Medicare rules state that grab bars are not covered because 
they are not primarily medical in nature.  
 
While a grab bar may be appropriate in this case, neither the Plan nor Medicare offers coverage of this item. 
You may wish to contact the Plan per your EOC to be explained how to use your OTC benefit for this item. 
Therefore, we decided that the Plan does not have to pay for a grab bar.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the emergency ambulance transportation (A0429) and 
ground mileage (A0425) provided on April 17, 2021. 
 
You asked the Plan to pay for the emergency ambulance transportation and ground mileage. You say that you 
billed this claim on May 5, 2021. You also say that you would like this claim to be reconsidered for coverage. 
The Plan denied your request. The Plan says this claim was not received by the Plan until July 5, 2022, which 
was 444 days after the date of service. 
 
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 emergency ambulance transportation and ground mileage was not filed 
until July 5, 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 emergency ambulance 
transportation (A0429) and ground mileage (A0425) provided on April 17, 2021.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a computed tomography (CT) scan of the lower back. 
 
You asked the Plan to pre-approve a CT scan of the lower back. You say that you are requesting a CT of the 
enrollee's back to see if their discs have moved inflamed. The Plan denied your request. The Plan says the 
documentation does not show that the enrollee meets the criteria for coverage. 
 
The Plan must follow Medicare rules. Medicare rules say that CT scans are covered only when they are 
medically necessary.  
 
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 CT scan of the lower back. Our 
reviewer says that the submitted records do not establish the medical necessity of the requested CT of the 
lumbar spine. Our physician reviewer found there is no listed contraindication to a magnetic resonance imaging 
(MRI) if cross sectional imaging is shown to be medically necessary. Our reviewer also found that an 
unenhanced CT of the lumbar spine is a poor test for disc pathology with an MRI being the procedure of choice 
unless contraindicated by an implanted device or other unusual contraindication. 
 
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 CT scan of the lower back have not been met. Therefore, we decided that the 
Plan does not have to pre-approve a computed tomography (CT) scan of the lower back.