Persius/hicric huggingface dataset:
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a diagnostic eye exam provided on October 
12, 2021. 
 
You asked the Plan to waive the copayment for the eye exam. You say that the exam should be considered in-
network. The Plan denied your request. The Plan says you have been charged the correct cost sharing amount. 
 
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 $25 
copayment for vision services in a specialist's office.  
 
The file shows that the Plan reprocessed the claim to reflect the correct $25 copayment, and have begun 
processing reimbursement for the difference already paid. Therefore, you are only responsible for the $25 
copayment for the eye exam. The eye exam falls within the Vision Care benefit category. This means that you 
have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a 
contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan 
does not have to waive the copayment for a diagnostic eye exam provided on October 12, 2021.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the spinal fusion (CPT code(s): 22612, 22614 and 
22842). 
 
You asked the Plan to pre-approve the spinal fusion. You say that the services are necessary. The Plan denied 
your request. The Plan says there was no documentation of additional visits taking place nor documentation of 
any new contraindication (a specific situation in which a drug, procedure, or surgery should not be used 
because it may be harmful to the person) to ongoing physical therapy. The Plan states the records further states 
the enrollee underwent an injection on June 8, 2022; however, there is no documentation of post-procedural 
pain level and no additional medical notes beyond those originally submitted. 
 
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 spinal fusion. Our reviewer says 
that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found only one recent physical therapy (PT) episode is documented. More physical therapy 
is needed. 
 
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 spinal fusion have not been met. Therefore, we decided that the Plan does 
not have to pre-approve the spinal fusion (CPT code(s): 22612, 22614 and 22842).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for autograft services provided to the enrollee on June 18, 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 records do not support the services billed. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
In this case, the CPT Code Manual definition of code 20937 is "Autograft for spine surgery only (includes 
harvesting the graft); morselized (through separate skin or fascial incision) (List separately in addition to code 
for primary procedure)." 
 
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 records do not documented 
autograft harvesting from a separate incision during the surgery. 
 
 
 
 
 
 We looked at this coder's review, the file, and Medicare rules. The denied code cannot be verified in the 
records. 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 autograft services provided to the enrollee on 
June 18, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve pneumatic compressor, segmental home model without 
calibrated gradient pressure (CPT code E0651) and segmental pneumatic appliance for use with pneumatic 
compressor, full leg (CPT code E0667). 
 
You asked the Plan to pre-approve the DME. You say that the enrollee has a long history of lymphedema and 
has attempted to manage this chronic disease with conservative measures for over 4 weeks without significant 
improvement. You state the enrollee is seeking additional in-home daily treatment option with a PCD to 
complement the current conservative treatments. The Plan denied your request. The Plan says the enrollee has 
not had a four-week trial of conservative therapy documented by measurements of the legs. 
 
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 DME. Our physician reviewer 
found the provided documentation did not clearly report before and after leg measurements to objectively 
report changes directly related to the therapy. Therefore, without sufficient evidence provided of a failed 
conservative treatment trial, this request for pneumatic compressor/appliance will be considered not medically 
necessary at this time. 
 
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 DME have not been met. Therefore, we decided that the Plan does not have 
to pre-approve pneumatic compressor, segmental home model without calibrated gradient pressure (CPT code 
E0651) and segmental pneumatic appliance for use with pneumatic compressor, full leg (CPT code E0667).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve insertion of subcutaneous cardiac rhythm monitor (CPT 
code 33285). 
 
You asked the Plan to pre-approve the service. You say that the service is necessary. The Plan denied your 
request. The Plan says the enrollee has not had any syncopal episodes (have not passed out) and have not used 
an external heart monitor. 
 
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 service. Our physician reviewer 
found insertion of an implantable loop recorder (ILR) would not be considered medically appropriate and 
necessary in this enrollees clinical management. 
 
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 service have not been met. Therefore, we decided that the Plan does not 
have to pre-approve insertion of subcutaneous cardiac rhythm monitor (CPT code 33285).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve right and left knee braces and hip braces with 
accessories (CPT code(s): L1690 and L1843 x2) 
 
You asked the Plan to pre-approve the braces. You say that the braces are necessary. The Plan denied your 
request. The Plan says the information sent in by the enrollee's doctor did not provide the information needed to 
determine if these braces were medically necessary. The Plan states for consideration of these devices, the Plan 
would need to see evidence on x-ray that the enrollee has advanced arthritis. The Plan states given the 
extensive amount of bracing requested with this authorization, it would also need to be demonstrated how the enrollee would physically be able to put on these braces and use them regularly such that they would benefit 
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 braces. Our physician reviewer 
found there was insufficient evidence provided of objective instability or description of practically how the 
enrollee would be able to use and benefit from these braces to support this request. Therefore, these braces will 
be considered not medically 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 braces have not been met. Therefore, we decided that the Plan does not have 
to pre-approve right and left knee braces and hip braces with accessories (CPT code(s): L1690 and L1843 x2)
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 70450 billed for date of service February 20, 
2022. 
 
You asked the Plan to pay for procedure code 70450. You say that you would like this claim reprocessed as 
medically necessary. The Plan denied your request. The Plan says payment for code 70450 is bundled into 
payment for code 70496. 
 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, we have confirmed that code 70450 
is a column II code to column I code 70496. This claim has not been billed with an appropriate modifier to 
bypass the edit. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we 
decided that the Plan does not have to pay for procedure code 70450 billed for date of service February 20, 
2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the MyoPro powered arm brace (CPT code L8702). 
 
You asked the Plan to pre-approve the MyoPro powered arm brace. You say that the brace is necessary. The 
Plan denied your request. The Plan says experimental and investigational procedures are not covered by 
Medicare. 
 
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 MyoPro powered arm brace. Our 
reviewer says that the requested items/services are not considered medically reasonable and necessary in this 
case. Our physician reviewer found there is insufficient medical literature to support the use of the MyoPro and 
it cannot be considered to be at least as beneficial as existing and available medically appropriate treatment for 
the enrollee's condition. 
 
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 MyoPro powered arm brace have not been met. Therefore, we decided that 
the Plan does not have to pre-approve the MyoPro powered arm brace (CPT code L8702).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a wrist-hand orthosis (L3916) provided on February 25, 
2022. 
 
You asked the Plan to pay for a wrist-hand orthosis. You say that the item at issue was a medical necessity for 
the enrollee. The Plan denied your request. The Plan says rules for payment for DMEPOS 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 and when the information in the enrollees medical record adequately 
supports the medical necessity for the item. 
 
The record does not contain a valid proof of delivery nor relevant medical records which support medical 
necessity for the supplies provided in this case. The document provided as proof of delivery in this case does 
not specify the item delivered. The available medical records do not discuss the item at issue. The record shows that the Plan made several attempts to obtain the necessary documentation without success. Therefore, we 
decided that the Plan does not have to pay for a wrist-hand orthosis (L3916) provided on February 25, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the complete series x-ray (D0210) provided on March 16, 
2022. 
 
You asked the Plan to pay for the dental service. You say that the dental service should be covered. The Plan 
denied your request. The Plan says your benefit for the complete series x-ray has already been exhausted. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, certain limitations apply. The record 
shows your benefit for the complete series x-ray was exhausted on date of service July 29, 2021. Therefore, we 
decided that the Plan does not have to pay for the complete series x-ray (D0210) provided on March 16, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for inpatient hospital care provided from 
January 4, 2022, to January 8, 2022. 
 
You asked the Plan to waive the copayment for the inpatient care. You say that insurance already paid more 
than what was billed. The Plan denied your request. The Plan says you have been charged the correct cost 
sharing amount. 
 
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 $245 per 
day for days 1-8 and $0 per day for additional days for each inpatient admission.  
 
The file shows that you were in the hospital from January 4, 2022, to January 8, 2022. You have only been 
asked to pay $245 per day for the first 3 days of inpatient care. The total for your stay is $735 ($245 copayment 
x 3 days = $735). Please note that the Plan can pay the provider the contracted rate regardless of the actual 
amount billed. This does not affect your copayment amount. The inpatient care falls within the Inpatient Hospital Care benefit category. This means that you have been asked to pay the correct amount based on your 
contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the 
Plan. Therefore, we decided that the Plan does not have to waive the copayment for inpatient hospital care 
provided from January 4, 2022, to January 8, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a domiciliary or rest home visit provided on October 14, 
2021, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for a domiciliary or rest home visit. You say that you are appealing with supporting 
records. The Plan denied your request. The Plan says the services performed by the non-participating provider 
on October 14, 2021, was not authorized by the Plan. The Plan also says that this was not referred by a 
participating 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 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 a domiciliary or rest home visit provided on 
October 14, 2021, by an out-of-network (OON) provider.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve insertion of subcutaneous cardiac rhythm monitor (CPT 
code 33285). 
 
You asked the Plan to pre-approve the service. You say that the service is necessary. The Plan denied your 
request. The Plan says the device is not being requested for recurrent fainting. 
 
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 service. Our physician reviewer 
found insertion of an implantable loop recorder (ILR) would not be considered medically appropriate and 
necessary in this enrollees clinical management. 
 
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 service have not been met. Therefore, we decided that the Plan does not 
have to pre-approve insertion of subcutaneous cardiac rhythm monitor (CPT code 33285).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit provided on March 9, 2022, by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for the office visit. You say that you have resubmitted the claim with supporting 
documentation and would like for it to be reprocessed for payment. The Plan denied your request. The Plan 
says the rendering provider is an OON provider and there was no referral from an in-network provider or an 
approved authorization. Also, the service rendered was not urgent or emergent. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
  The requested provider in this case is not a network provider with the Plan. The Plan had network providers 
available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the 
item/service at issue. We found no exception that would require the Plan to pay for these items/services. 
Therefore, we decided that the Plan does not have to pay for an office visit provided on March 9, 2022, by an 
out-of-network (OON) provider.
Appeal type: Hospice
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the emergency department visit (99285) and 
electrocardiogram (EKG) (93010 x 2) provided on March 17, 2021. 
 
You asked the Plan to pay for the physician services. You say that the medically necessary services were 
rendered to the enrollee in good faith. The Plan denied your request. The Plan says the enrollees claim would 
be covered under Original Medicare as it is responsible for coverage of Part B benefits starting on the date of 
election until the last day of the month in which hospice is revoked. The Plan also says it is the providers 
responsibility to verify the enrollees coverage before rendering services and to know proper billing procedures 
for a Medicare Advantage member on hospice. 
 Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice 
services. Medicare hospice pays for claims related to the terminal illness. The rules say that the Plan may direct 
the provider to bill Medicare directly for these services.  
 
The enrollee was under the Medicare hospice benefit for the dates of service at issue in this appeal. Therefore, 
we decided that the Plan does not have to pay for the emergency department visit (99285) and 
electrocardiogram (EKG) (93010 x 2) provided on March 17, 2021.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99284 billed for date of service November 
16, 2021. 
 
You asked the Plan to pay for procedure code 99284. The Plan denied your request. The Plan says payment for 
code 99284 is bundled into payment for code 99285. 
 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, we have confirmed that code 99284 
is a column II code to column I code 99285. This claim has not been billed with an appropriate modifier to 
bypass the edit. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we 
decided that the Plan does not have to pay for procedure code 99284 billed for date of service November 16, 
2021.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for wheelchair van transportation services provided to the 
enrollee on February 15, 2022. 
 
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 this is considered non-emergent, and there was no authorization. 
 
The Plan must follow Medicare rules. The rules say that Medicare does not pay for wheelchair van transport 
services.  
 
The services you have asked the Plan to pay for are wheelchair van transport services. Therefore, we decided 
that the Plan does not have to pay for wheelchair van transportation services provided to the enrollee on 
February 15, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the Tempus Gene panel testing coded as 81206, 81275, 
81276, 81292, 81295, 81298, 81317, 81404, 81301, 81162, and 81191 provided October 14, 2021. 
 
You asked the Plan to pay for the laboratory services. You say that you request reconsideration of this 
determination and coverage of the Tempus Gene Panel test at the in-network benefit level. The Plan denied 
your request. The Plan says the testing performed was not FDA approved and 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. Medicare rules say that providers must report services correctly. Providers must 
report services with the appropriate CPT code. 
 
We looked at the file, and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the laboratory services have not been met. Therefore, we decided that the Plan does not have to pay 
for the Tempus Gene panel testing coded as 81206, 81275, 81276, 81292, 81295, 81298, 81317, 81404, 81301, 
81162, and 81191 provided October 14, 2021.