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

 
We decided that the Plan does not have to provide reimbursement for the home COVID-19 test kits purchased 
on January 15, 2022. 
 
You asked the Plan to provide reimbursement for the COVID test kits. You say that the President issued a rule 
that requires the Plan to cover these test kits. The Plan denied your request. The Plan says the Plan did not 
begin to offer this coverage until February 1, 2022. 
 
The Plan must follow Medicare rules. Medicare rules say that reimbursement is offered for home COVID 
testing kits provided after April 4, 2022. 
 We looked at the file and Medicare rules. These test kits were purchased before Medicare coverage for the kits 
was allowed. It should be noted that the Plan has indicated that reimbursement was allowed as a supplemental 
benefit as of February 1, 2022, before Medicare required the Plan to begin providing this coverage. Based on 
this information, we decided that Medicare rules for coverage of the at-home COVID-19 test kits have not been 
met. Therefore, we decided that the Plan does not have to provide reimbursement for the home COVID-19 test 
kits purchased on January 15, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the specialist office visit provided on 
November 30, 2021. 
 
You asked the Plan to waive the copayment for the specialist office visit. You say that you shouldn't be charged 
for a follow-up visit. The Plan denied your request. The Plan says the copayment was applied 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 $20 
copayment for each in-person specialist visit.  
 
You have been asked to pay a $20 for the specialist office visit. The specialist office visit falls 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 copayment for the specialist office visit provided on November 30, 2021.
Appeal type: Outpatient Mental Health
Decision: Favorable

 
We decided that the Plan has to pay for outpatient mental health services provided on December 3, 2021. 
 
You asked the Plan to pay for outpatient mental health services. You say that you received emergency room 
services. The Plan denied your request. The Plan says that the services provided were out-of-network outpatient 
mental health services. The Plan only covers in-network outpatient mental health services. 
 
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and 
diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or 
payment. The rules also say that an emergency exists based on a prudent layperson standard, not a retrospective 
medical review. For symptoms to be considered emergent in nature, they must be such that a prudent layperson 
with an average knowledge of medicine would reasonably expect the absence of immediate medical attention 
would result in serious jeopardy to their health. 
 
The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their 
decision to deny your request. The Plan did not provide any medical records or evidence to support a denial of 
payment for this service. Without medical records, we cannot determine whether the services provided were 
emergency care or outpatient mental health services. Therefore, we decided that the Plan has to pay for 
outpatient mental health services provided on December 3, 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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve electrical stimulation (unattended), to one or more areas 
for indication(s) other than wound care, as part of a therapy plan of care (G0283). 
 
You asked the Plan to pre-approve the chiropractic services. You say that you scheduled appointments with a 
licensed chiropractor related to sciatica pain. The Plan denied your request. The Plan says this service is not a 
covered benefit. 
 
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 pre-approve electrical stimulation (unattended), to one or more areas for indication(s) 
other than wound care, as part of a therapy plan of care (G0283).
Appeal type: Inpatient Hospital
Decision: Favorable

 
We decided that the Plan has to pay for the acute inpatient hospital care provided from January 5, 2022, to 
January 10, 2022. 
 
You asked the Plan to pay for acute inpatient hospital care. You say that the enrollee required inpatient 
anticoagulation evaluation and titrations due to failed outpatient therapy. The Plan denied your request. The 
Plan says that the denial of payment for inpatient level of care is correct, because this stay should have been 
observation level of care. 
 
The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor 
expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases, 
consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or 
more. 
 
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 pay for acute inpatient hospital care. Our reviewer 
says that the documentation supports that the criteria for inpatient payment are met in this case. Our physician 
reviewer found the enrollee was transferred to the hospital on January 5, 2022 with a diagnosis finding of non-
occlusive deep vein thrombosis in one of two popliteal veins. The enrollee was treated then discharged when 
considered medically stable on January 10, 2022. At the time of inpatient admission the admitting physician 
reasonably expected that the enrollee's necessary hospital care (including earlier emergency department and/or 
observation care) would span at least 2 midnights. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of acute inpatient hospital care have been met. Therefore, we decided that the Plan 
has to pay for the acute inpatient hospital care provided from January 5, 2022, to January 10, 2022.  
 
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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a disposable sensor for a continuous glucose monitoring 
(CGM) system (A9276) and external transmitter for a CGM system (A9277). 
 
You asked the Plan to pre-approve a disposable sensor and an external transmitter for a CGM system. You say 
that you disagree with the denial and would like the plan to reconsider coverage. The Plan denied your request. 
The Plan says the service requested has a status indicator code of I on the Medicare 2022 National Physician 
Fee Schedule, which indicates that the services are not valid for Medicare purposes. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
We find that CPT code A9276 and A9277 has a Status Indicator of I on the Physician Fee Schedule. This 
means that CPT code A9276 and A9277 is not valid for Medicare purposes. Based on this information, we 
decided that Medicare rules for coverage of a disposable sensor and an external transmitter for a CGM system 
have not been met. Therefore, we decided that the Plan does not have to pre-approve a disposable sensor for a 
continuous glucose monitoring (CGM) system (A9276) and external transmitter for a CGM system (A9277).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve additional non-emergency taxi transportation (A0100). 
 
You asked the Plan to pre-approve additional transportation. The Plan denied your request. The Plan says you 
have exhausted the established benefit of 24 one-way trips. 
 
Medicare does not cover transport in a vehicle that is not an ambulance. However, the Plan offers a 
transportation benefit that exceeds Medicare coverage. For that reason, the Plans coverage rules apply in this 
case. The Plan covers a maximum of 24 one-way trips per year.  
 
 
  We looked at your request, the records in the case file, and the rules. Based on this information, we decided 
that you have exhausted the Plan maximum benefit for coverage of routine transportation. Therefore, we 
decided that the Plan does not have to pre-approve additional non-emergency taxi transportation (A0100).
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for ambulance service with no transportation provided on 
December 3, 2021. 
 
You asked the Plan to pay for ambulance service. You say that you cannot believe the Plan would not cover 
this to help its members. The Plan denied your request. The Plan says this service is not covered by Medicare. 
 
The Plan must follow Medicare rules. The rules say that Medicare does not pay for ambulance services when 
there is no transport.  
 
The ambulance company did not provide transport services on December 3, 2021. The ambulance benefit is a 
transportation benefit. When there is no transport, neither Medicare nor the Plan pays for the services provided. 
Therefore, we decided that the Plan does not have to pay for ambulance service with no transportation provided 
on December 3, 2021.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for at home COVID-19 test kits provided on January 16, 2022. 
 
You asked the Plan to pay for at-home COVID-19 test kits. You say that according to what was being said on 
the news a person could order up to 8 tests per household and it would be covered by insurance. The Plan 
denied your request. The Plan says the denial of payment for these test kits is correct, because these are not 
covered by Medicare. 
 
The Plan must follow Medicare rules. Medicare rules say that starting April 4, 2022, Medicare covers over-the-
counter COVID-19 tests at no cost to Medicare enrollees, including those with Medicare Advantage (MA) 
plans. Medicare will only pay for claims with dates of service starting on or after April 4, 2022, and for patients 
enrolled in a MA plan, claims should be submitted to Original Medicare. 
 
We looked at the file and Medicare rules. These test kits were purchased on January 16, 2022, which was 
before Medicare began coverage for over-the-counter COVID-19 tests. Based on this information, we decided 
that Medicare rules for coverage of at-home COVID-19 test kits have not been met. Therefore, we decided that 
the Plan does not have to pay for at home COVID-19 test kits provided on January 16, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the refraction testing provided on December 27, 2021. 
 
You asked the Plan to pay for the refraction testing. You say that this should be covered in full. The Plan 
denied your request. The Plan says this is not covered by Medicare. 
 
The Plan must follow Medicare rules. The rules say that Medicare does not cover routine vision services such 
as refraction testing. 
 
Although this may have been appropriate testing, Medicare does not pay for this. Your Plan does not offer a 
supplemental benefit that covers this routine vision care. Therefore, we decided that the Plan does not have to 
pay for the refraction testing provided on December 27, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve office visit with an ophthalmologist (99203), visual 
field exam (92250), eye exam with photos (92060), and special eye evaluation to be provided by the requested 
out-of-network provider. 
 
You asked the Plan to pre-approve office visit with an ophthalmologist, visual field exam, eye exam with 
photos, and special eye evaluation to be provided by the requested out-of-network provider. The Plan denied 
your request. The Plan says the medical care you require can be provided by a network provider. 
 
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 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 office 
visit with an ophthalmologist (99203), visual field exam (92250), eye exam with photos (92060), and special 
eye evaluation to be provided by the requested out-of-network provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve epidural steroid injections (64483). 
 
 
You asked the Plan to pre-approve epidural steroid injections. The Plan denied your request. The Plan says the 
epidural steroid injections are not medically necessary. 
 
The Plan follows Medicare rules.  
 
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 epidural steroid injections. Our 
reviewer says that epidural steroid injections are not medically reasonable or necessary. Our physician reviewer 
found that the Medicare LCD criteria is 3 months of pain relief, not 5 weeks. The request is therefore, at this 
point, deemed 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 epidural steroid injections have not been met. Therefore, we decided that the 
Plan does not have to pre-approve epidural steroid injections (64483).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a phone holder and power seat elevation feature for a 
power wheelchair (K0108, E2300). 
 
You asked the Plan to pre-approve the phone holder and power seat elevation feature. You say that these 
features are medically necessary. The Plan denied your request. The Plan says these features are considered 
convenience features and are non-covered. 
 
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a 
medical purpose.   
 
The items at issue in this appeal do not serve a purpose that is primarily medical in nature. Therefore, we decided that the Plan does not have to pre-approve a phone holder and power seat elevation feature for a power 
wheelchair (K0108, E2300).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for molecular pathology testing provided to the enrollee on 
September 6, 2021. 
 
You asked the Plan to pay for the testing. You say that this should be paid for. The Plan denied your request. 
The Plan says if a laboratory assays two or more genes in a patient in parallel, then those two or more genes 
will be considered part of the same panel. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
We find that the various denied CPT codes are not supported in the medical record. Specifically, the testing at 
issue in this case should be reported with CPT 81479. Based on this information, we decided that Medicare 
rules for coverage of the testing have not been met. Therefore, we decided that the Plan does not have to pay 
for molecular pathology testing provided to the enrollee on September 6, 2021.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for surgical services provided to the enrollee on September 28, 
2021. 
 
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. 
The Plan says the billed codes are not supported. 
 
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 the denied codes is: 
 
14301 - Adjacent tissue transfer or rearrangement, any area; defect 30.1 sq cm to 60.0 sq cm 
 
14302 - Adjacent tissue transfer or rearrangement, any area; each additional 30.0 sq cm, or part thereof (List 
separately in addition to code for primary procedure) 
 
42950 - Pharyngoplasty (plastic or reconstructive operation on pharynx) 
 We asked our coder to carefully review the case file and apply the relevant Medicare rules to determine if the 
Plan was correct in denying the request to pay for the services. Our reviewer says that the services at issue in 
this case were not supported by the medical records. Our reviewer found that in terms of CPT 14301 and 
14302, the operative report describes undermining, and therefore adjacent tissue transfer or rearrangement 
cannot be verified. In terms of CPT 42950, the operative report does not describe plastic or reconstructive 
surgery on the pharynx in cases where direct wound closure or reapproximation is not possible. This procedure 
changes the shape of the soft palate and pharynx. This description was referenced with codify. 
 
We looked at this coder'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 pay for surgical services provided to the enrollee on September 28, 2021.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pay for skilled nursing facility (SNF) services provided to the 
enrollee on December 10, 2021. 
 
You asked the Plan to pay for the services. You say that according to your contract as of 12/1/21, you do not 
bill by the Patient-Driven Payment Model (PDPM) anymore. The Plan denied your request. The Plan says a 
corrected claim can be submitted. 
 The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate code. 
 
We find that the SNF services at issue in this case were not supported. SNF claims must use PDPM codes for 
payment. 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 pay for skilled nursing facility (SNF) services 
provided to the enrollee on December 10, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Freestyle Lite test strips. 
 
You asked the Plan to pre-approve Freestyle Lite test strips. You say that that you would like reconsideration 
because the enrollee has already used this brand. The Plan denied your request. The Plan says the enrollee does 
not meet exception criteria for coverage of a non-preferred brand of testing supplies. 
 
The Plan must follow Medicare rules. Medicare rules 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. 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 Freestyle Lite test strips have been 
met. Specifically, the documentation submitted does not include any clinical information to verify that the 
enrollee has tried and failed the Plan's preferred brands or that the Plan's preferred brands would be 
contraindicated for the enrollee. Therefore, we decided that the Plan does not have to pre-approve Freestyle 
Lite test strips.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for laboratory services provided to the enrollee on September 
29, 2021. 
 
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. 
The Plan says only code should be submitted for this panel. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
We find that the various denied CPT codes are not supported in the medical record. Specifically, the testing at 
issue in this case should be reported with CPT 81479. 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 pay 
for laboratory services provided to the enrollee on September 29, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve physician's services to be provided by the requested 
out-of-network provider. 
 
You asked the Plan to pre-approve physician's services to be provided by the requested out-of-network 
provider. The Plan denied your request. The Plan says out-of-network services are for emergencies and/or if 
there is not a contracted specialist in the network. As per the medical group, the members records do not show 
a medical emergency. 
 
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 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 
physician's services to be provided by the requested out-of-network provider.