Persius/hicric huggingface dataset:
Appeal type: Outpatient Therapies
Decision: Unfavorable

 We decided that the Plan does not have to pay for the radiation therapy planning and treatment aids (77334 and 
77263) provided on March 10, 2021. 
 You asked the Plan to pay for the radiation therapy planning and treatment aids. You say that you would like 
reconsideration based on the records submitted. The Plan denied your request. The Plan says the documentation 
submitted does not support the services billed. 
 The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. The 
rules also say that for Medicare to consider coverage and payment for any item or service, the information 
submitted by the supplier or provider must corroborate the documentation in the beneficiary's medical 
documentation and confirm that Medicare coverage criteria have been met. 
 In this case, the CPT Code Manual definition of code 77263 is therapeutic radiology treatment planning; 
complex. 
 The CPT Code Manual definition of code 77334 is  treatment devices, design and construction; complex 
(irregular blocks, special shields, compensators, wedges, molds or casts). 
 We find that CPT codes 77334 and 77263 are not supported in the record. Specifically, the submitted 
documentation does not include any medical records to verify if Medicare coverage criteria have been met. Of 
note, the record indicates that the Plan requested these records and none were received. Based on this 
information, we decided that Medicare rules for coverage of the radiation therapy planning and treatment aids 
have not been met. Therefore, we decided that the Plan does not have to pay for the radiation therapy planning 
and treatment aids (77334 and 77263) provided on March 10, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for the shoulder orthosis you received on 
April 16, 2021. 
 
You asked the Plan to waive the coinsurance for the shoulder orthosis. You did not provide an argument with 
your appeal request. The Plan denied your request. The Plan says you were charged this coinsurance 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 20% 
coinsurance for prosthetic devices and related supplies.  
 
You have been asked to pay 20% coinsurance for the shoulder orthosis. The shoulder orthosis falls within the 
prosthetic devices 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 
the shoulder orthosis you received on April 16, 2021.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pay for home health services provided to the enrollee from August
24, 2020 to August 26, 2020 and billed under code S9330.

You asked the Plan to pay for these services. You say that this claim should be paid. The Plan denied your
request. The Plan says code S9330 is assigned a status code I = Not valid for Medicare purposes. As the claim
was billed with a CPT code which is invalid for usage with Medicare; the Plan finds that Medicare rule for
payment of this claim has not been met. The Plan would accept a submission of a corrected claim to consider
services for payment.

The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly.
Providers must report services with the appropriate codes. In this case the status indicator associated with the
code prevents payment on Medicare claims. Therefore, we decided that the Plan does not have to pay for home
health services provided to the enrollee from August 24, 2020 to August 26, 2020 and billed under code S9330.
Appeal type: Other
Decision: Favorable

We decided that the Plan has to hold you harmless for non-covered supplies coded as A9270 billed from July 2,
2021 to July 4, 2021.

You asked the Plan to hold you harmless for these supplies. You say that this bill should be covered by the
Plan. The Plan denied your request. The Plan says that your participating provider billed a code or service not
covered by Medicare.

Medicare rules say that a contract provider is an agent of the plan. Services and referrals given by a contract
provider are considered approved by the plan unless notice is provided that the services will not be covered.
The Plan follows these rules. These supplies were billed to you by a Plan contract provider. You would have no
knowledge of what codes are or are not covered by Medicare. The file does not show that the Plan provided
notice that these supplies would not be covered prior to being received. Under Medicare rules, this means these
charges are covered by the Plan. The Plan must work with the Plan contract provider to make sure you are not
billed for these supplies. Therefore, we decided that the Plan has to hold you harmless for non-covered supplies
coded as A9270 billed from July 2, 2021 to July 4, 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 pay for the x-ray services provided on March 22, 2021 by an out-of-network (OON) provider.

You asked the Plan to pay for the x-ray services. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the services billed are not payable.

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 x-ray services provided on March 22, 2021 by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for these services.  
 
You asked the Plan to pay for these services. You say that these services should be covered by the Plan and you 
should have four visits remaining. The Plan denied your request. The Plan says based on the services allowed 
under both acupuncture and chiropractic services, your visits were exhausted. 
 
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 Plan offers extended benefits for chiropractic 
and acupuncture services beyond what Medicare cover. Therefore, the Plans rule apply in this case.  
The records these benefits were exhausted at the time of service. Therefore, we decided that the Plan does not 
have to pay for chiropractic services provided from June 16, 2021 to July 21, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the home visit provided on June 8, 2021 by an out-of-network (OON) provider.

You asked the Plan to pay for the home visit. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the services rendered are not a covered benefit.

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 home visit provided on June 8, 2021 by an out-of-network (OON) provider
Appeal type: DME/ Orthotics
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve additional power wheelchair accessories (E2311, 
E2313, E2377) for the enrollee. 
 You asked the Plan to pre-approve the accessories. You say that this is medically necessary. The Plan denied 
your request. The Plan says this 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 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 accessories. Our reviewer says that 
the requested accessories are not considered medically reasonable and necessary in this case. Our physician 
reviewer found based on the medical records provided, there is no documentation that the enrollee meets the 
Medicare criteria for these additional accessories. The records indicate the enrollee has 4+/5 right upper 
extremity strength and is modified independent for eating and grooming, thus indicating he has adequate upper 
extremity strength and function to control the wheelchair's power options with their own switches. 
 
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 accessories have not been met. Therefore, we decided that the Plan does not 
have to pre-approve additional power wheelchair accessories (E2311, E2313, E2377) for the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay physician services provided to the enrollee on April 23, 2021 and billed under code 99224.

You asked the Plan to pay this claim. You say that these services should be paid. The Plan denied your request. The Plan says this service cannot be billed to the same patient twice on the same day.

The Plan states a review determined that this claim denied because only 1 unit per date of service is allowed for this service. The claim history shows this code was billed under a different claim by the same provider for the same date of service. 

The Plan must follow Medicare rules. Medicare rules say that if more than one service is provided on the same day to the same patient by the same physician or more than one physician in the same specialty in the same group, only one service may be reported unless the services are for unrelated problems. Based on the documentation provided, this claim cannot be paid as billed due to the physician group relationship between the two providers and the omission of the modifier required to identify this as a separate and distinct service. Medicare billing criteria were not met. Therefore, we decided that the Plan does not have to pay physician services provided to the enrollee on April 23, 2021 with code 99224.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve destruction of paravertebral facet joint nerves.

You asked the Plan to pre-approve the services. You say that this is medically necessary. The Plan denied your request. The Plan says the records do not show the levels to be treated.

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 services. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found the requirement is for two sets of diagnostic medial branch blocks, each of which provide greater than 80% pain relief. In this case, only one set has been done at each level. Therefore, the criteria are not met, and the request at this time is not medically reasonable or necessary. 

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the services have not been met. Therefore, we decided that the Plan does not have to pre-approve destruction of paravertebral facet joint nerves.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve oncology services to be provided by an out-of-network 
(OON) provider. 
 
You asked the Plan to pre-approve these services. You say that you do not want to change providers and have 
agreed to specific treatment with this provider. The Plan denied your request. The Plan says the services are 
available from network providers. 
 
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. 
 
The requested provider in this case is not a network provider with the Plan. The Plan has network providers 
available who can provide the items/services at issue in this appeal. We found no exception that would require 
the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve 
oncology services to be provided by an out-of-network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve sensors for a continuous glucose monitor (K0553). 
 
You asked the Plan to pre-approve sensors for a continuous glucose monitor. 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. The rules state that DMEPOS is covered only when there are both a 
physician order and proof of delivery.  
 
The record does not contain a valid physician order for the supplies provided in this case. Therefore, we 
decided that the Plan does not have to pre-approve sensors for a continuous glucose monitor (K0553).
Appeal type: Lab
Decision: Unfavorable

 We decided that the Plan does not have to pay for lab services provided to the enrollee on May 26, 2021 codes 
as 70450 and 71045.  
You asked the Plan to pay for these services. You say that this claim should be paid. The Plan denied your 
request. The Plan says this testing is not covered for screening purposes. 
 
The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few 
tests listed in the Medicare rules section, are not covered. The test at issue in this appeal was requested solely 
for screening purposes. Medicare does not cover this test solely for screening purposes. Therefore, we decided 
that the Plan does not have to pay for lab services provided to the enrollee on May 26, 2021 codes as 70450 and 
71045.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for a face down recovery system (E1399) provided on February 24, 2021.

You asked the Plan to pay for the face down recovery system. You say that the item was medically necessary. The Plan denied your request. The Plan says there were network providers available.

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 at issue in this appeal. The Plan did not pre-approve the item at issue. We found no exception that would require the Plan to pay for these items. Therefore, we decided that the Plan does not have to pay for a face down recovery system (E1399) provided on February 24, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve an expandable controller (E2377) with harness (E2313) 
and electronic connection (E2311), a power seat elevation system (E2300), and a transfer bar and smart check 
coded K0108 for a power wheelchair. 
 
You asked the Plan to pre-approve an expandable controller with harness and electronic connection, a power 
seat elevation system, and a transfer bar and smart check. You say that the requested items are a medical 
necessity for the enrollee. The Plan denied your request. The Plan says medical necessity rules for the 
requested items have not been met. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary or do not serve a primarily medical purpose 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 an expandable controller with harness 
and electronic connection. Our reviewer says that an expandable controller with harness and electronic 
connection are not considered medically reasonable and necessary in this case. Our physician reviewer found 
that there is no documentation that the enrollee meets coverage criteria for an expandable controller with 
harness and electronic connection. Records report the enrollee is independent with grooming, toileting, and 
eating, thus indicating that the enrollee has adequate upper extremity strength and function to control the 
wheelchair's power options with their own switches. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of an expandable controller with harness and electronic connection have not been 
met. A power seat elevation system, a transfer bar, and smart check do not serve a purpose that is primarily 
medical in nature. Therefore, we decided that the Plan does not have to pre-approve an expandable controller 
(E2377) with harness (E2313) and electronic connection (E2311), a power seat elevation system (E2300), and a 
transfer bar and smart check coded K0108 for a power wheelchair.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Zilretta. 
 
You asked the Plan to pre-approve Zilretta. You say that you would like the plan to reconsider their denial. The 
Plan denied your request. The Plan says the requested drug does not meet step therapy criteria. 
 
 
 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 Zilretta. Our reviewer says that the 
documentation does not support that the requested drug meets step therapy criteria. Our physician reviewer 
found the enrollee has osteoarthritis of the knees. The provided records do not indicate that the enrollee has 
tried and failed the plan's preferred step one alternatives. The record does not indicate that the enrollee has a 
contraindication to, or would have an adverse effect from the plan's preferred step one alternatives. Therefore, 
the enrollee does not meet criteria for the requested drug. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Zilretta have not been met. Therefore, we decided that the Plan does not have to 
pre-approve Zilretta.
Appeal type: ER
Decision: Unfavorable

 We decided that the Plan does not have to pay for emergency room services provided to the enrollee on June 
28, 2021. 
 
You asked the Plan to pay for these services. You say that this claim should be paid. The Plan denied your 
request. The Plan says this claim was not billed correctly based on the Medicare coding regulations. Code  
69209 has a professional/technical indicator of 5. This indicator identifies codes that describe a service incident 
to physician services for which payment may not be made when they are provided to hospital inpatients or 
patients in a hospital outpatient department. Therefore, as the billed place of service code is 23 for Emergency 
Room-Hospital the rule for payment of CPT code 69209 has not been met. The Plan states they would accept a 
submission of a corrected claim to consider service for payment. The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code and Place of Service code. 
 
In this case, this claim cannot be paid due to an issue between the CPT code and the Place of Service code 
reported. Medicare rules for coverage of these services have not been met. Therefore, we decided that the Plan 
does not have to pay for emergency room services provided to the enrollee on June 28, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayments for the optometry visit and the visual field testing you had on July 14, 2021.

You asked the Plan to waive the copayments for the optometry visit and the visual field testing. You say that the visual field testing results were not readable. You don't think you should have to pay these copayments because the doctor didn't do anything for you. The Plan denied your request. The Plan says these copayments were 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 $45 copayment for vision care visits and a $25 copayment for diagnostic tests. 

You have been asked to pay a $45 copayment for the optometry visit and a $25 copayment for the visual field testing. These copayments apply even if you were not satisfied with the results of the 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 copayments for the optometry visit and the visual field testing you had on July 14, 2021.