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

 
We decided that the Plan does not have to pay for paramedic intercept provided to the enrollee on December 
24, 2021. 
 
You asked the Plan to pay for paramedic intercept. You say that this bill should be paid by the Plan. The Plan 
denied your request. The Plan says paramedic services are not covered by Medicare. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for advanced life support (ALS), in 
accordance with state and local laws by an emergency medical technician (EMT) intermediate or EMT-
Paramedic only in certain circumstances. Medicare allows ALS paramedic intercept services only when the services are furnished under a contract with a qualified basic life support (BLS), the provision of medically 
necessary supplies and services, with a volunteer ambulance company. In addition, State law must not allow 
the volunteer ambulance company to bill for the transport or BLS services.  
 
The Plan has confirmed that the provider does not have a contract with the volunteer ambulance company that 
provided the transport services. Therefore, we decided that the Plan does not have to pay for paramedic 
intercept provided to the enrollee on December 24, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve compression stockings identified with code A6531. 
 You asked the Plan to pre-approve the compression stockings. You say that you need these items or your blood 
sugar will go down and you will have to have surgery. The Plan denied your request. The Plan says you do not 
meet criteria for the requested items. 
 
The Plan must follow Medicare rules. Medicare rules say that compression stockings described by code A6531 
are covered only when they are used to treat an open venous stasis ulcer. Medicare rules also say that 
compression bandages and gradient compression wraps are covered only when they are used as dressings over 
a qualifying wound. 
 
The record does not show that you have open venous stasis ulcers or a qualifying wound. This means that you 
do not have a medical condition for which compression stockings can be covered or paid for by Medicare. 
Therefore, we decided that the Plan does not have to pre-approve compression stockings identified with code 
A6531.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a medical eye exam (92014) and an eye refraction (92015) 
provided on January 20, 2022, by an out-of-network (OON) provider. 
 You asked the Plan to pay for a medical eye exam and an eye refraction. You say that you were told that the 
provider was in your Plan's network. The Plan denied your request. The Plan says vision services are covered 
when they are received from a provider in the specified vision network. 
 
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 received from a provider who participates in the Plans 
specified vision network. 
 
We looked at the file and the Plan's rules. The provider in this case is not part of the Plans vision network. The 
Plan covers vision services when they are received from a provider who participates in the Plans specified 
vision network. Based on this information, we decided that the Plan's rules for coverage of a medical eye exam 
and an eye refraction have not been met. Therefore, we decided that the Plan does not have to pay for a medical 
eye exam (92014) and an eye refraction (92015) provided on January 20, 2022, by an out-of-network (OON) 
provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services. 
 
You asked the Plan to pre-approve the LTACH services. You say that the requested admission to a LTACH is 
medically necessary. The Plan denied your request. The Plan says the requested admission to a LTACH does 
not meet criteria. 
 
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically 
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 
 
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 LTACH services. Our reviewer says 
that the requested LTACH care is not considered medically reasonable and necessary in this case. Our 
physician reviewer found the record indicates that the enrollee is improving but still requires acute care 
services before transitioning to a lower level of care. The enrollee continues to receive acute care services, and 
these have not been denied. The medical record does not indicate that the enrollee requires services that she is 
not currently receiving but that would be available at the LTACH facility. 
 
 
 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 LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve long term acute care hospital (LTACH) services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a home COVID-19 test purchased on January 5, 2022. 
 
You asked the Plan to pay for this home test. You say that the cost of this test should be covered by the Plan. 
The Plan denied your request. The Plan says per the Plans COVID19 policy, coverage applies to eligible tests 
that are purchased on or after February 1, 2022. Therefore, they are unable to approve your request as this 
benefit was not in effect at the time of your purchase. 
 
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. 
 Medicare covers COVID-19 testing provided in  a professional setting for present symptoms or when ordered 
by a health directive. Home tests purchased for preventative measures or patient convenience are not covered 
by Medicare or the Plan. Therefore, we decided that the Plan does not have to pay for a home COVID-19 test 
purchased on January 5, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a pneumatic compression device (E0652) and accessory 
(E0667). 
 
You asked the Plan to pre-approve a pneumatic compression device and accessory. You say that this is 
medically necessary. The Plan denied your request. The Plan says the requirements for coverage have not been 
met. 
 
The Plan follows Medicare rules. The rules state that a PCD coded as E0652 is covered for the treatment of 
lymphedema extending onto the chest, trunk and/or abdomen after a four-week trial of conservative therapy 
demonstrating failed response to treatment with an E0650 or E0651. At least four weeks of regular, daily, 
multiple-hour home usage of the E0650 or E0651 is required. If the base PCD is not covered, related 
accessories are not eligible for reimbursement. 
 
We looked at the file and Medicare rules. Based on this information we decided that Medicare rules for 
coverage of the PCD have not been met. Specifically, the record does not show that the enrollee had at least 
four weeks of regular, daily, multiple-hour home usage of the E0650 or E0651 after careful, in-person fitting, 
training and supervision by a technician who is skilled in and who regularly and successfully uses the appliance 
provided. Therefore, we decided that the Plan does not have to pre-approve a pneumatic compression device 
(E0652) and accessory (E0667).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve additional diabetic testing supplies. 
 
You asked the Plan to pre-approve the requested services. You say that the enrollee tests up to three times a 
day. The Plan denied your request. The Plan says the enrollee does not meet guidelines for additional testing 
supplies. 
 
 The Plan must follow Medicare rules. Medicare rules say that if quantities of test strips or lancets that exceed 
the utilization guidelines are provided and criteria are not met, the amount in excess will be denied as not 
reasonable and necessary. 
 
We looked at the file and Medicare rules. The file shows that 20 units of test strips (1000 strips), and 10 units 
of lancets (1000 lancets) were requested. The Plan has agreed to pre-approve 8 units of test strips (400 strips) 
and 4 units of lancets (400 lancets). The approved amount will allow the enrollee to test the requested 3-times 
per day. Therefore, we decided that the Plan does not have to pre-approve additional diabetic testing supplies.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for ambulance response with no transport provided on January 3, 
2022. 
 
You asked the Plan to pay for ambulance response with no transport. You say that you believe the Plan should 
pay this bill. The Plan denied your request. The Plan says ambulance response with no transport is not covered. 
 
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 January 3, 2022. 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 response 
with no transport provided on January 3, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve massage therapy. 
 
You asked the Plan to pre-approve massage therapy. You say that massage therapy is medically necessary. The 
Plan denied your request. The Plan says massage therapy is not covered. 
 
The Plan must follow Medicare rules. Medicare does not cover the services of a massage therapist. Therefore, 
we decided that the Plan does not have to pre-approve massage therapy.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for ambulance response with no transport provided on January 
12, 2022. 
 
You asked the Plan to pay for ambulance response with no transport. You say that this bill should be 
reimbursed by the Plan. The Plan denied your request. The Plan says ambulance response with no transport is 
not covered. 
 
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 January 12, 2022. 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 response 
with no transport provided on January 12, 2022.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve use of Botox (botulinum toxin). 
 
You asked the Plan to pre-approve Botox. You say that you are appealing with supporting records. The Plan 
denied your request. The Plan says the denial of authorization for this drug is correct, because the enrollee does 
not meet criteria for Botox. 
 
The Plan follows Medicare rules. Medicare rules say that onabotulinumtoxin-A such as Botox may be covered 
for certain indications. 
 
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 Botox. Our reviewer says that the 
enrollee does not meet the Medicare criteria for the requested use of Botox. Our physician reviewer found the 
enrollee does not have any of the Medicare-approved indications for coverage of Botox. Gastroparesis is not a 
medically-accepted indication for Botox as defined by Medicare. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Botox have not been met. Therefore, we decided that the Plan does not have to 
pre-approve use of Botox (botulinum toxin).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a walker purchased on January 1, 2022. 
 
You asked the Plan to pay for this walker. You say that you could not get this walker from a Plan provider. The 
Plan denied your request. The Plan says you did not have prior authorization to purchase equipment from a 
provider who is not a Medicare eligible provider. 
 
The Plan must follow Medicare rules. The rules say that no Medicare payment may be made to a beneficiary 
for items or services provided directly by vendor or retailer who is not eligible to take Medicare payment.  
 
This equipment was purchased from a provider is not a Medicare eligible provider. Therefore, we decided that 
the Plan does not have to pay for a walker purchased on January 1, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve compression stockings identified with code A6530. 
 
You asked the Plan to pre-approve the compression stockings. You say that this enrollee has venous 
insufficiently with lower extremity edema and needs compression stockings to help with the circulation in her 
legs and to reduce the edema. The Plan denied your request. The Plan says this item is not a covered benefit. 
 
The Plan must follow Medicare rules. The rules say that compression stockings described by code A6530 are 
noncovered because they do not meet the statutory definition of a surgical dressing.  
 
 
 Although this item may be appropriate, it does not fall into a covered benefit category and cannot be paid for 
by Medicare or the Plan. Therefore, we decided that the Plan does not have to pre-approve compression 
stockings identified with code A6530.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for observation care discharge day management (99217) 
provided on December 19, 2021. 
 
You asked the Plan to pay for observation care discharge day management. You say that you have provided 
records to support the service billed. 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. 
 
In this case, the Plan has attested that it has not received a claim for initial or subsequent observation care. The 
record therefore does not support the use of the discharge day code 99217. Based on this information, we 
decided that Medicare rules for coverage of observation care discharge day management have not been met. 
Therefore, we decided that the Plan does not have to pay for observation care discharge day management 
(99217) provided on December 19, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for medical services provided to the enrollee on December 2, 
2020. 
 
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 filed timely. 
 
The Plan follows Medicare rules. The rules say that claims for services furnished on or after January 1, 2010, 
must be filed no later than one calendar year after the date of service. The record shows that a claim for these 
services was not filed until January 7, 2022. This means that more than one calendar year from the date of 
service had passed before a claim was filed. Therefore, we decided that the Plan does not have to pay for 
medical services provided to the enrollee on December 2, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a total electric hospital bed purchased for the enrollee on 
December 8, 2020. 
 
You asked the Plan to pay for this equipment. You say that a total electric hospital bed was medically 
necessary. The Plan denied your request. The Plan says a total electric hospital bed is not covered by Medicare. 
 
The Plan must follow Medicare rules. Medicare rules say that a total electric hospital bed is not covered.  
 
While a total electric hospital bed may be appropriate in this case, neither the Plan nor Medicare offers 
coverage for this item. Therefore, we decided that the Plan does not have to pay for a total electric hospital bed 
purchased for the enrollee on December 8, 2020.
Appeal type: Testing
Decision: Favorable

 
We decided that the Plan has to reimburse you for the 6 over the counter coronavirus test kits provided on 
January 18, 2022. 
 
You asked the Plan to reimburse you for the over the counter coronavirus test kits. You say that you were 
advised that covid tests could be submitted for possible reimbursement prior to February 1, 2022. The Plan 
denied your request. The Plan says that the coronavirus tests were purchased prior to the plan benefit going into 
effect on February 2, 2022. The Plan also says that reimbursement cannot be made. 
 
The Plan must follow Medicare rules. Medicare rules say that plans and insurers are required to cover at-home 
over-the-counter COVID-19 tests purchased on or after January 15, 2022. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the over the counter coronavirus test kits have been met. Therefore, we decided that the Plan has to 
reimburse you for the 6 over the counter coronavirus test kits provided on January 18, 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: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services provided on July 6, 2021. 
 
You asked the Plan to pay for the lab services. You say that these services were medically necessary and 
should be paid. 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 July 6, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services provided on April 21, 2021. 
 
You asked the Plan to pay for the lab services. You say that these services were medically necessary and 
should be paid. 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 April 21, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services provided on March 12, 2021. 
 
You asked the Plan to pay for the lab services. You say that these services were medically necessary and 
should be paid. 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 March 12, 2021.
Appeal type: Drugs
Decision: Favorable

 
We decided that the Plan has to pre-approve Keytruda for the enrollee. 
 
You asked the Plan to pre-approve Keytruda. You say that this is medically necessary. The Plan denied your 
request. The Plan says that that expert opinion and NCCN guidelines do not recommend the combination of 
drugs requested. 
 
The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for anti-cancer 
drugs if they are medically accepted as safe and effective or appropriate for the particular use.  
 
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 Keytruda. Our reviewer says that 
Keytruda is medically reasonable and necessary. Keytruda is not FDA-approved for the enrollees diagnosis. 
Keytruda is supported by one of the major drug compendia or by clinical research that appears in a CMS-
approved medical journal. Keytruda is safe and effective and otherwise reasonable and necessary for this 
enrollee. Our physician reviewer found that the enrollee's condition meets criteria for coverage of Keytruda. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Keytruda have been met. Therefore, we decided that the Plan has to pre-approve 
Keytruda for the enrollee.  
 
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: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the lab services provided on December 27, 2021. 
 
You asked the Plan to pay for the lab services. The Plan denied your request. The Plan says these services are 
not payable. 
 
The Plan must follow Medicare rules. Medicare rules state that routine ESRD lab services are not separately 
payable. Labs should bill the facility directly for lab services as they are considered part of the composite rate. 
No other payment for these services is allowed. Therefore, we decided that the Plan does not have to pay for 
the lab services provided on December 27, 2021.