Persius/hicric huggingface dataset:
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home health services provided to the enrollee from 
December 12, 2021, to December 18, 2021. 
 
You asked the Plan to pay for home health services. You say that you would like the Plan to reconsider their 
denial of payment. The Plan denied your request. The Plan says the services are not covered as billed. 
 
The Plan must follow Medicare rules. The rules say that certain data elements on the RAP and the claim must 
be completed for home health care services to be covered. 
 
We looked at the claim submitted, the file and the Medicare rules. The rules say the Type of Bill is a required 
data element needed to submit a claim under home health PPS. This 4-digit code gives two pieces of 
information. The first three digits indicate the base type of bill. The fourth digit indicates the sequence of this 
bill in this particular episode of care. The type of bill accepted for HH PPS requests for anticipated payment are 
either 7, 8, or 9 as defined above. HHAs must submit HH PPS claims with the 4th digit of "9." Therefore, we 
decided that the Plan does not have to pay for the home health services provided to the enrollee from December 
12, 2021, to December 18, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the genetic testing (0037U) provided on January 25, 2022. 
 
You asked the Plan to pay for code 0037U. You say that you would like the Plan to reconsider their denial of 
payment. The Plan denied your request. The Plan says the services are not covered. 
 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 gene panel provided includes the FANCC gene. In addition to 
single gene testing, MolDX will also deny panels of tests that include the FANCC gene. Based on this 
information, we decided that Medicare rules for coverage of code 0037U have not been met. Therefore, we 
decided that the Plan does not have to pay for the genetic testing (0037U) provided on January 25, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the initial hospital care (99221) provided on August 6, 2021. 
 
You asked the Plan to pay for code 99221. You say that you would like the Plan to reconsider their denial of 
payment. The Plan denied your request. The Plan says the services are not covered 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 looked at the file and Medicare rules. Review of the file shows the claim was billed with an outpatient 
place of service code of 32. Code 99221 is an inpatient hospital care code. The claim should be billed with the 
correct code for outpatient nursing facility services. Therefore, we decided that the Plan does not have to pay 
for the initial hospital care (99221) provided on August 6, 2021.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Negative Pressure Wound Therapy (NPWT). 
 
You asked the Plan to pre-approve Negative Pressure Wound Therapy (NPWT). You say that the requested 
NPWT is medically necessary. The Plan denied your request. The Plan says the enrollee does not meet criteria 
for Negative Pressure Wound Therapy (NPWT). 
 
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 Negative Pressure Wound Therapy 
(NPWT). Our reviewer says that the enrollee does not meet criteria for Negative Pressure Wound Therapy 
(NPWT). Our physician reviewer found the enrollee was being treated for primary osteoarthritis of the right 
ankle and foot. He presented with right ankle pain that is persistent and has been progressively getting worse. 
The exam reveals no evidence of chronic venous stasis or chronic lymphostasis, and skin is intact. Sensation is 
grossly intact. Strength is intact. He has increased pes planovalgus on the right compared to the left. There is 
good ankle range of motion as it is subtalar and transverse tarsal motion. Tenderness to palpation is noted to the 
anterior lateral ankle. X-rays are noted to show end-stage valgus right ankle arthritis; moderate midfoot arthritis 
especially navicular medial cuneiform is noted. He is planned to undergo a right ankle arthroplasty.   
However, detailed documentation is not evident regarding this enrollee having any ulcers including pressure 
ulcer, venous or arterial insufficiency ulcers, or a chronic ulcer of mixed etiology. Additionally, there is no 
indication of a need for accelerated healing for the surgically created wound. Documentation of completion of a 
wound program is also not documented. There is no compelling rationale presented or extenuating 
circumstances noted to support the medical necessity of this request as an exception to guidelines. Therefore, 
the enrollee does not meet Medicare criteria for the requested NPWT. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Negative Pressure Wound Therapy (NPWT) have not been met. Therefore, we 
decided that the Plan does not have to pre-approve Negative Pressure Wound Therapy (NPWT).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the drug test (G0482) provided on January 24, 2022. 
 
You asked the Plan to pay for code G0482. 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 providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
In this case, the CPT Code Manual definition of code G0482 is Drug test(s), definitive, utilizing (1) drug 
identification methods able to identify individual drugs and distinguish between structural isomers (but not 
necessarily stereoisomers), including, but not limited to gc/ms (any type, single or tandem) and lc/ms (any type, 
single or tandem and excluding immunoassays (e.g., ia, eia, elisa, emit, fpia) and enzymatic methods (e.g., 
alcohol dehydrogenase)), (2) stable isotope or other universally recognized internal standards in all samples 
(e.g., to control for matrix effects, interferences and variations in signal strength), and (3) method or drug-
specific calibration and matrix-matched quality control material (e.g., to control for instrument variations and 
mass spectral drift); qualitative or quantitative, all sources, includes specimen validity testing, per day; 15-21 drug class(es), including metabolite(s) if performed. 
 
We find that CPT code G0482 is not supported in the medical record. Specifically, the record does not contain 
evidence that definitive testing on 15-21 drug classes was performed. Based on this information, we decided 
that Medicare rules for coverage of code G0482 have not been met. Therefore, we decided that the Plan does 
not have to pay for the drug test (G0482) provided on January 24, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a whirlpool tub. 
 
You asked the Plan to pre-approve a whirlpool tub. You say that the item is necessary. The Plan denied your 
request. The Plan says the requested item is not primarily medical in nature. 
 
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 whirlpool tub.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit provided on February 16, 2022, by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for the office visit. You say that it was medically necessary to treat the enrollee. The 
Plan denied your request. The Plan says the rendering provider is an OON provider and there was no approved 
authorization. Also, the service rendered was not urgent or emergent. 
 
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 an office visit provided on February 16, 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 an office visit provided on March 24, 2022, by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for an office visit. 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 it was 
determined these services can be received in-network. 
 
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 an office visit provided on March 24, 2022, by an 
out-of-network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the outpatient office visit (99204) provided 
on May 6, 2022. 
 
You asked the Plan to waive the copayment for the outpatient office visit. You say that you received a routine 
annual eye exam, and no cost sharing should apply. The Plan denied your request. The Plan says you received a 
Medicare-covered vision exam to diagnose conditions of the eye. The Plan also says the copayment amount 
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 $40 
copayment for Medicare-covered Vision care.  
 
 
 
 You have been asked to pay a $40 copayment for the outpatient office visit. This outpatient office visit falls 
within the Medicare-covered 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 the outpatient office visit (99204) provided on May 6, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for chiropractic services provided on October 18, 2021, to 
December 27, 2021, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for chiropractic services. You say that you were under the impression that this would 
be a Medicare claim and you did not know that a referral was needed. 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 
chiropractic services. We found no exception that would require the Plan to pay for the chiropractic services. 
The records provided for review do not show that the chiropractic services at issue were urgent or emergent. 
Therefore, we decided that the Plan does not have to pay for chiropractic services provided on October 18, 
2021, to December 27, 2021, by an out-of-network (OON) provider.
Appeal type: Other
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Desvenlafaxine. 
 
You asked the Plan to pre-approve Desvenlafaxine. You say that the medication is necessary. The Plan denied 
your request. The Plan says the enrollee's plan does not have a Medicare Part D benefit, or a separate pharmacy 
benefit managed by the plan, therefore self-administered drugs do not meet the criteria for coverage. 
 
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-
administered drugs. The self-administered drugs requested here are not among the types which are covered by 
Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve Desvenlafaxine.  
 
Benefits for Desvenlafaxine may be available under Medicare Part D. Contact the Plan that administers Part D 
benefits for further information concerning any benefits and appeal rights.
Appeal type: Hospice
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services provided on February 28, 2022. 
 
You asked the Plan to pay for the laboratory services. You say that the enrollee revoked their hospice election 
prior to the date of service in this case. The Plan denied your request. The Plan says the enrollees claim would 
be covered under Original Medicare as it is responsible for coverage of Part B benefits starting on the date of 
election until the last day of the month in which hospice is revoked. The Plan also says it is the providers 
responsibility to verify the enrollees coverage before rendering services and to know proper billing procedures 
for a Medicare Advantage member on hospice. 
 
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 February 10, 2022. The services in question were provided 
before the end of that month. Therefore, we decided that the Plan does not have to pay for the laboratory 
services provided on February 28, 2022.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home health services provided from November 2, 2021, 
to November 30, 2021. 
 
You asked the Plan to pay for the home health services. You say that this is a final claim for home care. You 
also say that this should pay without issue. The Plan denied your request. The Plan says there was no exception 
request was submitted to waive the 5-day requirement for filing the RAP claim due to a circumstance beyond 
the provider's control. 
 
The Plan must follow Medicare rules. Medicare rules say that all Home Health Agencies (HHAs) must submit 
a request for anticipated payment (RAP) within 5 calendar days after the start of care date for initial 30-day 
periods and within 5 calendar days after the from date for each subsequent 30-day period of care, which is set 
at 0 percent at the beginning of every 30-day period. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the home health services have not been met. Specifically, the record indicates the RAP was not 
submitted within 5 days of the from the start of care date, November 2, 2021. Therefore, we decided that the Plan does not have to pay for the home health services provided from November 2, 2021, to November 30, 
2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the deluxe frame (V2025) and progressive lens (V2781) 
provided on March 1, 2022 by an out-of-network (OON) provider. 
 
You asked the Plan to pay for the glasses. You say that you relied on the recap which does not state you must 
use a participating provider. You also say that you feel you should not be penalized for something that was not 
made clear by the Plan. The Plan denied your request. The Plan says you received these services from a 
provider who is not in the Plan's network. The Plan also says that OON vision care services are not covered. 
 
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 when they are provided by participating providers. 
 
 
 
 We looked at the file and the Plan's rules. The record shows that you received these glasses from an OON 
provider. Based on this information, we decided that the Plan's rules for coverage of the glasses have not been 
met. Therefore, we decided that the Plan does not have to pay for the deluxe frame (V2025) and progressive 
lens (V2781) provided on March 1, 2022 by an out-of-network (OON) provider.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home health services provided from November 19, 2021, 
to December 15, 2021. 
 
You asked the Plan to pay for the home health services. You say that the claim was submitted according to the 
Plan's requirements. The Plan denied your request. The Plan says there was no exception request submitted to 
waive the 5-day requirement for filing the RAP claim due to a circumstance beyond the provider's control. 
 
The Plan must follow Medicare rules. Medicare rules say that all Home Health Agencies (HHAs) must submit 
a request for anticipated payment (RAP) within 5 calendar days after the start of care date for initial 30-day 
periods and within 5 calendar days after the from date for each subsequent 30-day period of care, which is set 
at 0 percent at the beginning of every 30-day period. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the home health services have not been met. Specifically, the record indicates the RAP was not 
submitted within 5 days of the from the start of care date, November 19, 2021. Therefore, we decided that the 
Plan does not have to pay for the home health services provided from November 19, 2021, to December 15, 
2021.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for cataract surgery provided on January 17, 2022, by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for the cataract surgery. You say that the service was medically necessary. 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 
cataract surgery. We found no exception that would require the Plan to pay for the cataract surgery. The 
records provided for review do not show that the cataract surgery was urgent or emergent.  Therefore, we decided that the Plan does not have to pay for cataract surgery provided on January 17, 2022, by 
an out-of-network (OON) provider.
Appeal type: Hospice
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the critical care service (99291) provided on November 11, 
2021. 
 
You asked the Plan to pay for the evaluation and management service. You say that the service should be 
covered. The Plan denied your request. The Plan says the enrollees claim would be covered under Original 
Medicare as it is responsible for coverage of Part B benefits starting on the date of election until the last day of 
the month in which hospice is revoked. The Plan also says it is the providers responsibility to verify the 
enrollees coverage before rendering services and to know proper billing procedures for a Medicare Advantage 
member on hospice. 
 
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 the critical care service (99291) provided on November 11, 
2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the exam provided on March 23, 2022, by an out-of-network 
(OON) provider. 
 
You asked the Plan to pay for the exam. You say that you have seen this provider numerous times over the 
years. You also say that you feel this service should be covered. The Plan denied your request. The Plan says 
you were seen by a provider who does not participate in the Plan's network. The Plan also says that there was 
no evidence that seeing a network provider would be detrimental to your health or that it is medically necessary 
for you to see a provider outside of the Plan's Vision Care network. 
 
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 the exam provided on March 23, 2022, by an out-
of-network (OON) provider.