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

 
We decided that the Plan does not have to pay for lab services provided on June 27, 2021. 
 
You asked the Plan to pay for the lab services. You say that you billed these services correctly. The Plan denied 
your request. The Plan says you billed with an incorrect place of service on the claim. 
 The Plan must follow Medicare rules. Medicare rules say that lab services, the POS code must reflect the 
location in which the sample was taken. POS code 81 is used to describe samples taken by the laboratory 
directly. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the lab services have not been met. Specifically, this claim was billed with the laboratory POS 
code. The records do not support that the sample was taken in a laboratory setting. Therefore, we decided that 
the Plan does not have to pay for lab services provided on June 27, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a stair glide provided on November 6, 2020. 
 
You asked the Plan to pay for a stair glide. The Plan denied your request. The Plan says this item is not a 
covered benefit. 
 
The Plan covers all items that Medicare covers. Medicare rules state that stair lifts are not covered because they 
are not primarily medical in nature.  
 
While a stair lift may be appropriate in this case, neither the Plan nor Medicare offers coverage of this item. 
Therefore, we decided that the Plan does not have to pay for a stair glide provided on November 6, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an expandable controller, harness and electronic 
connector to 2 power options. 
 
You asked the Plan to pre-approve an expandable controller, harness and electronic connector to 2 power 
options. You say that the services are necessary. The Plan denied your request. The Plan says based on the 
documentation provided, coverage criteria has not been met. 
 
The Plan follows Medicare rules. Medicare rules say that wheelchair accessories are covered when specific 
criteria are met. 
 
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, harness and 
electronic connector to 2 power options. Our reviewer says that the services are not medically necessary. Our 
physician reviewer found the expandable controller (E2377), expandable controller harness (E2313), and 
electro connect (E2311) and other types of proportional input devices (e.g., mini-proportional or compact 
joysticks, touchpads, chin control, head control, etc.) are not medically necessary per Local Coverage Article: 
Wheelchair Options/Accessories - Policy Article (A52504). You do not require non-proportional input devices 
(e.g., sip and puff, head array, etc.). You do not require a separate display (i.e., for alternate control devices), 
other electronic devices (e.g., control of an augmentative speech device or computer through the chair's drive 
control), or an attendant control. You have 3 power options of tilt, recline, and power elevating leg rests but 
you do not need to control the power options through a joystick. Your upper extremity strength and function 
support that you can control any power options through 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, harness and electronic connector to 2 power options 
have not been met. Therefore, we decided that the Plan does not have to pre-approve an expandable controller, 
harness and electronic connector to 2 power options.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services provided on June 23, 2021. 
 
You asked the Plan to pay for the lab services. You say that you billed these services correctly. The Plan denied 
your request. The Plan says you billed with an incorrect place of service on the claim. 
 
The Plan must follow Medicare rules. Medicare rules say that lab services, the POS code must reflect the 
location in which the sample was taken. POS code 81 is used to describe samples taken by the laboratory 
directly. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the lab services have not been met. Specifically, this claim was billed with the laboratory POS 
code. The records do not support that the sample was taken in a laboratory setting. Therefore, we decided that 
the Plan does not have to pay for lab services provided on June 23, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the telehealth services provided on February 19, 2021. 
 
You asked the Plan to pay for the billed services. The Plan denied your request. The Plan says there is no 
established relationship with this provider. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly.  
 We looked at the file and the rules. The enrollee received a telemedicine office visit for pain. There is no 
indication that the enrollee was referred by his primary care physician. The record provided appears to be a 
phone conversation with the enrollee presenting his problems. The records do not include previous physical 
exams, testing, or imaging to confirm a diagnosis or condition. Based on this information, we decided that 
Medicare rules for coverage of the billed services have not been met. Therefore, we decided that the Plan does 
not have to pay for the telehealth services provided on February 19, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the office visit (99202) provided on March 16, 2021.  
You asked the Plan to pay for the office visit. You say that you would like reconsideration based on the records 
submitted. The Plan denied your request. The Plan says there is not an established relationship between the 
enrollee and ordering physician. 
 
The Plan must follow Medicare rules. Medicare rules say that unless provided otherwise, other services 
included on the Medicare telehealth services list must be furnished using, at a minimum, audio and video 
equipment permitting two-way, real-time interactive communication between the patient and distant site 
physician or practitioner. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the office visit have not been met. Specifically, the documentation does not clearly indicate that the 
service was furnished using audio and video equipment permitting two-way, real-time interactive 
communication between the patient and distant site physician or practitioner. CPT code 99202 is not included 
on the list of codes which are appropriate for audio-only telehealth services. The documentation does not 
clearly show if this service was furnished using audio-only or audio-video communication. Therefore, we 
decided that the Plan does not have to pay for the office visit (99202) provided on March 16, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for acute inpatient rehabilitation facility (IRF) admission and 
services. 
 
You asked the Plan to pay for IRF care. You say that the hospital does not offer occupational therapy and not 
enough physical therapy, without IRF the enrollee won't return to baseline functionality. The Plan denied your 
request. The Plan says based on Medicare guidelines, the requested IRF services do not meet the requirements 
for approval. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 
 
 
 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 IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found that the complexity of the enrollees nursing, medical and rehabilitation needs does 
not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. Medical 
problems are stable. There are no complex nursing or rehabilitation needs. While the documentation does 
support a need for physical and/or occupational therapy, there is no documented need for an intensive, multi-
disciplinary rehabilitation program. There is not a reasonable expectation that the enrollee will be able to fully 
participate in and benefit from the intensive rehabilitation therapy program provided in an IRF. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pay for acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the non-emergent ambulance transportation services (A0428, 
A0425) provided on October 29, 2021. 
 
You asked the Plan to pay for the ambulance services. You say that these services were medically necessary. 
The Plan denied your request. The Plan says the non-emergent ambulance services did not meet the criteria for 
medical necessity on the date in question. 
 
Medicare pays for ambulance services only when they are medically reasonable and necessary. The Plan 
follows the same 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 pay for the ambulance services. Our reviewer says 
that the ambulance transportation was not medically necessary. Our physician reviewer found that the enrollee 
with multifocal neuropathy had an inability to walk up and down stairs. She was transported via ambulance 
non-emergently to the infusion center for a scheduled appointment. She was assisted down the stairs to the 
stretcher and transported without treatment or incident. The documentation does not support that other means 
of transport (such as stretcher van, wheelchair van, taxi, private car, or other type of vehicle) were 
contraindicated for this enrollee on October 29, 2021. The documentation does not support that the enrollee 
needed the expertise, services and lifesaving and life sustaining equipment that only a fully-equipped 
ambulance can provide for safe transport. The documentation does not support that the ambulance transport was medically reasonable and necessary for this enrollee on October 29, 2021. 
 
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 ambulance services have not been met. Therefore, we decided that the Plan 
does not have to pay for the non-emergent ambulance transportation services (A0428, A0425) provided on 
October 29, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the eyewear (V2103, V2203, V2020), provided on October 
25, 2021. 
 
You asked the Plan to pay for the eyewear. You say that the items should be covered. The Plan denied your 
request. The Plan says you have exceeded the Plan's maximum allowance for eyewear and are responsible for 
the difference. 
 
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 eyewear with an allowance of $250 per a Plan year. 
 
We looked at the file and the Plan's rules. You have exceeded the Plan's maximum allowance for eyewear and 
are responsible for the difference. Based on this information, we decided that the Plan's rules for coverage of 
the eyewear have not been met. Therefore, we decided that the Plan does not have to pay for the eyewear 
(V2103, V2203, V2020), provided on October 25, 2021.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a repair of incisional or ventral hernia (49561) and a suture 
of small intestine (44602) provided on May 27, 2021. 
 
You asked the Plan to pay for a repair of incisional or ventral hernia and a suture of small intestine. You say 
that you have provided medical records to support the medical necessity of the services at issue. The Plan 
denied your request. The Plan says rules for payment have not been met. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. Medicare rules also say that claims or claim 
lines that have been determined to be exact duplicates of another claim or claim line are denied. 
 
In this case, we have confirmed that code 49561 is a column II code to column I code 44602. Code 49561 has 
not been billed with an appropriate modifier to bypass the edit. Based on the claim submitted, Medicare billing 
criteria for code 49561 have not been met. Additionally, the Plan has documented that the claim for code 44602 
is a duplicate of a claim line in a prior claim that has been processed and paid. Medicare rules for coverage of a 
suture of small intestine have not been met. Therefore, we decided that the Plan does not have to pay for a 
repair of incisional or ventral hernia (49561) and a suture of small intestine (44602) provided on May 27, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for a continuous positive airway pressure 
(CPAP) machine and supplies provided from January 14, 2021, to January 22, 2021. 
 
You asked the Plan to waive the coinsurance for the CPAP machine and supplies. You say that the equipment 
was defective and you tried to return it. The Plan denied your request. The Plan says the correct coinsurance 
was applied. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a 20% 
coinsurance for durable medical equipment (DME), including CPAP machines and supplies. 
 
 Item Allowed Amount 20% Coinsurance 
CPAP Machine (E0601) $54.93 $10.99 
Nasal Mask Cushion (A7032) $23.91 $4.78 
Total:  $15.77 
 
You have been asked to pay $15.77, which is 20% of the allowed amount for the CPAP machine and supplies. 
The CPAP machine and supplies fall within the Durable Medical Equipment (DME) and Related Supplies 
benefit category. This means that you have been asked to pay the correct amount based on your contract with 
the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. 
Therefore, we decided that the Plan does not have to waive the coinsurance for a continuous positive airway 
pressure (CPAP) machine and supplies provided from January 14, 2021, to January 22, 2021.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the skilled nursing facility (SNF) care provided from 
September 20, 2021, to October 19, 2021. 
 
You asked the Plan to pay for the SNF care. You say that the services are coverable under the Medicare Act. 
The Plan denied your request. The Plan says the enrollee did not receive daily skilled services. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors 
listed in the Medicare rules section are met. Custodial care is 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 pay for the SNF care. Our reviewer says that the 
enrollee did not meet the Medicare criteria for SNF care. Our physician reviewer found the enrollee did not 
have daily skilled nursing needs that required the specialized skill, knowledge, and judgment of a skilled 
professional nurse. The enrollee did not have daily skilled therapy needs that required the specialized skill, 
knowledge, and judgment of a skilled professional therapist. The enrollee did not require daily skilled nursing 
and/or skilled therapy on an inpatient basis in a SNF setting. 
 
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 SNF care have not been met. Specifically, the file shows that the enrollee 
did not receive daily skilled services. Therefore, we decided that the Plan does not have to pay for the skilled 
nursing facility (SNF) care provided from September 20, 2021, to October 19, 2021.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Minuteman interspinous device for the enrollee. 
 
You asked the Plan to pre-approve these services. You say that these services are medically necessary. The 
Plan denied your request. The Plan says that the clinical value and effectiveness of the Minuteman interspinous 
device in the setting of severe lumbar stenosis has not been demonstrated in the peer-reviewed literature. 
 
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 these services. Our reviewer says that 
the requested services are not considered medically reasonable and necessary in this case. The minuteman 
spinous process distraction procedure is experimental. More research is needed to show safety and efficacy. 
Our physician reviewer found that the enrollee's condition does not meet criteria for coverage of these services. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of these services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve the Minuteman interspinous device for the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the office visit and chiropractic manipulative treatment 
provided on June 28, 2021, to July 14, 2021, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for the office visit and the chiropractic manipulative treatment. You say that the 
services are 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 
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 office visit and chiropractic manipulative 
treatment provided on June 28, 2021, to July 14, 2021, by an out-of-network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an eye exam (99204), an eye exam with photos (92250), 
a fluorescein angiography (92235) and ophthalmic diagnostic imaging (92134) to be provided by an out-of-
network (OON) provider. 
 
You asked the Plan to pre-approve an eye exam, an eye exam with photos, a fluorescein angiography and 
ophthalmic diagnostic imaging. You say that you would like to see the requested provider as the location is 
close to you. You also say you need to see someone who specializes in retinal detachment and the providers in 
network are too far. The Plan denied your request. The Plan says your Plan does not have out of network 
benefits except in the case of emergency, urgently needed services when the network is not available, or when 
out of area dialysis services are needed. The Plan also says there are in-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 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 
an eye exam (99204), an eye exam with photos (92250), a fluorescein angiography (92235) and ophthalmic 
diagnostic imaging (92134) to be provided by an out-of-network (OON) provider.
Appeal type: Outpatient Mental Health
Decision: Favorable

 
We decided that the Plan has to pay for the individual psychotherapy services (90832) provided October 25, 
2021. 
 
You asked the Plan to pay for the psychotherapy services. You say that the enclosed medical records clearly 
reflect the medical necessity for the services rendered. The Plan denied your request. The Plan says that the 
service is not supported without required documentation. 
 
The Plan must follow Medicare rules. The rules say that if consultations are unsuccessful, document the 
patients medical chart with the date and physician notification method. This does not apply if the physician 
referred the patient to the CP. 
 
We looked at the file, and Medicare rules. The submitted claim includes a referring provider for the services at 
issue. Documentation of a physician consultation does not apply when the physician has referred the 
beneficiary to the clinical psychologist. Based on this information, we decided that Medicare rules for coverage 
of the psychotherapy services have been met. Therefore, we decided that the Plan has to pay for the individual 
psychotherapy services (90832) provided October 25, 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.