Persius/hicric huggingface dataset:
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the seat lift mechanism, electric, any type (E0627) purchased 
September 15, 2022. 
 
You asked the Plan to pay for the seat lift mechanism. You say that the claim denied because the diagnosis 
code was missing. The customer service representative told you that the circled item on the prescription is the diagnosis code. Please review and act on this claim. The Plan denied your request. The Plan says Medicare 
policy does not cover this service. 
 
The Plan must follow Medicare rules. Medicare rules say that the provider, supplier, or beneficiary, as 
appropriate, must furnish to the intermediary or carrier sufficient information to determine whether payment is 
due and the amount of payment. 
 
We looked at the file and Medicare rules. Based on this information, we decided that there is insufficient 
information in the record to be able to determine if Medicare rules for coverage of the seat lift mechanism have 
been met. there is insufficient information to be able to determine the necessity of the service. There were no 
medical records provided in the case file. Therefore, we decided that the Plan does not have to pay for the seat 
lift mechanism, electric, any type (E0627) purchased September 15, 2022.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Morphine Sul. 
 
You asked the Plan to pre-approve Morphine Sul. You say that the medication is necessary. The Plan denied 
your request. The Plan says the enrollee's plan does not have a Medicare Part D benefit, or a separate pharmacy 
benefit managed by the plan, therefore self-administered drugs do not meet the criteria for coverage. 
 
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-
administered drugs. The self-administered drugs requested here are not among the types which are covered by 
Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve Morphine Sul.  
 
Benefits for Morphine Sul may be available under Medicare Part D. Contact the Plan that administers Part D 
benefits for further information concerning any benefits and appeal rights.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for inpatient hospital care provided from September 16, 2021, to 
September 22, 2021. 
 
You asked the Plan to pay for inpatient hospital care. You say that the claim was submitted within the original 
filing limit. The Plan denied your request. The Plan says per Medicare guidelines an original claim submission 
must be filed to the appropriate Medicare claims processing contractor no later than 12 months, or 1 calendar 
year, after the date the services were furnished. 
 
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 inpatient hospital care was not filed until November 8, 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 inpatient hospital care provided from September 16, 2021, to 
September 22, 2021.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for diagnostic radiology services provided on 
September 1, 2022. 
 
You asked the Plan to pay for diagnostic radiology services. You say that the services were medically 
necessary. The Plan denied your request. The Plan says non-emergent, non-urgent services with out-of-network 
providers require prior authorization. 
 
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 
service at issue. We found no exception that would require the Plan to pay for these services. Therefore, we 
decided that the Plan does not have to pay for diagnostic radiology services provided on September 1, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 70450 billed for date of service November 
11, 2022. 
 You asked the Plan to pay for procedure code 70450. You say that the claim was billed correctly and should be 
paid. 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 November 11, 
2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an ankle foot orthosis (AFO) provided on October 13, 2022. You asked the Plan to pay for the AFO. You say that the AFO was medically necessary. The Plan denied your 
request. The Plan says the Medicare criteria was not met. 
 
The Plan must follow Medicare rules. Medicare rules say that the information should include the patient's 
diagnosis and other pertinent information including, but not limited to, duration of the patient's condition, 
clinical course (worsening or improvement), prognosis, nature and extent of functional limitations, other 
therapeutic interventions and results, past experience with related items, etc.  
 
We looked at the file and Medicare rules. There is not sufficient documentation of the enrollees medical 
condition to substantiate the necessity for the ankle foot orthosis in dispute. Specifically, there was no 
information regarding the enrollees clinical course, prognosis, or the nature and extent of functional 
limitations. Based on this information, we decided that Medicare rules for coverage of the AFO have been met. 
Therefore, we decided that the Plan does not have to pay for an ankle foot orthosis (AFO) provided on October 
13, 2022.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pay for self-administered drugs provided from October 24, 2022, to 
October 28, 2022, and does not have to waive the copayment for the emergency room visit. 
 
You asked the Plan to pay for self-administered drugs and to waive the copayment for the emergency room 
visit. The Plan denied your request. The Plan says the medical records support outpatient services, not inpatient 
hospital care from October 25, 2022, to October 28, 2022. You remain responsible for the Part D drug charges. 
The Plan says the cost sharing was charged correctly for the emergency room visit 
 
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-
administered drugs. The self-administered drugs requested here are not among the types which are covered by 
Medicare Part B. Therefore, we decided that the Plan does not have to pay for self-administered drugs provided 
from October 24, 2022, to October 28, 2022. 
 
The Plan contract says that enrollees must pay a $90 copayment for emergency room visit. You can find this 
information on page 80 of the Plan's 2022 Evidence of Coverage (EOC). 
 
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 $90 
copayment for emergency room visits.  
 
You have been asked to pay a $90 copayment for the emergency room visit. This service falls within the 
emergency 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 the emergency room visit.  
 
Benefits for self-administered drugs may be available under Medicare Part D. Contact the Plan that administers 
Part D benefits for further information concerning any benefits and appeal rights.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 76641 billed for date of service August 30, 
2022. 
 
You asked the Plan to pay for procedure code 76641. You say that the claim was billed correctly and should be 
paid. The Plan denied your request. The Plan says the number of units billed exceeds the maximum allowed. 
 The Plan must follow Medicare rules. Medicare rules say that claims submitted where the unit of service 
exceeds the MUE value for the HCPCS/CPT code will be denied. 
 
In this case, the MUE for CPT code 76641 is 1. The MAI value for this code is 2. You billed 2 units of this 
code, exceeding the MUE. Specifically, you billed one line item of this code with the LT modifier and one line 
item of this code with the RT modifier instead of billing one line item with the bilateral modifier as is required. 
Based on this information, we decided that Medicare rules for coverage of procedure code 76641 have not been 
met. Therefore, we decided that the Plan does not have to pay for procedure code 76641 billed for date of 
service August 30, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Intracept Neuroablation Procedure (64628 and 
64629). 
 
You asked the Plan to pre-approve the Intracept Neuroablation Procedure. You say that this service is 
medically necessary. The Plan denied your request. The Plan says this service is considered experimental. 
 
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 Intracept Neuroablation Procedure. 
Our reviewer says that the requested services are not considered medically reasonable and necessary in this 
case. Our physician reviewer found this service is considered experimental. 
 
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 Intracept Neuroablation Procedure have not been met. Therefore, we 
decided that the Plan does not have to pre-approve the Intracept Neuroablation Procedure (64628 and 64629).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code(s) 88341, 88342, 88360, 88377, & 88381 
billed for date of service April 8, 2022. 
 
You asked the Plan to pay for procedure code(s) 88341, 88342, 88360, 88377, & 88381. You say that this 
service was medically necessary. The Plan denied your request. The Plan says this code is included in the 
facility payment and is not separately payable.  
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Technical components must be billed by the facility where the enrollee was an inpatient or outpatient and are 
not separately payable to the lab. 
 
The records indicate that the specimen was taken while the enrollee was an inpatient or outpatient. Per the 
Physician Fee Schedule, there is a Professional/Technical indicator of 1 for CPT code(s) 88341, 88342, 88360, 
88377, & 88381. This means there is both a professional and technical component for the CPT code(s). In this 
case, an appropriate modifier to indicate the professional component has not been billed with CPT code(s) 
88341, 88342, 88360, 88377, & 88381. Based on this information, we decided that Medicare rules for coverage 
of procedure code 88341, 88342, 88360, 88377, & 88381 have not been met. Therefore, we decided that the 
Plan does not have to pay for procedure code(s) 88341, 88342, 88360, 88377, & 88381 billed for date of 
service April 8, 2022.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the emergency department visits (99285) 
provided December 5, 2022, to December 15, 2022 
 
You asked the Plan to waive the copayment for the emergency visit. You say that you feel you should not have 
a copay for $100 because for both visits you were admitted within 24 hours and had a private room for both 
claims. The Plan denied your request. The Plan says this cost sharing was charged correctly. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay $100 
copayment for emergency room services for Emergency care.  
 
You have been asked to pay $200 copayment for the two emergency visits. This item/service falls within the 
Emergency 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 the emergency 
department visits (99285) provided December 5, 2022, to December 15, 2022
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the drug testing (80307, G0480) provided on March 23, 
2022, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for the drug testing. You say that this testing should be paid in full. The Plan denied 
your request. The Plan says this testing is not covered when provided OON without prior authorization. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The requested provider in this case is not a network provider with the Plan. The Plan had network providers available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the 
item/service at issue. We found no exception that would require the Plan to pay for these items/services. 
Therefore, we decided that the Plan does not have to pay for the drug testing (80307, G0480) provided on 
March 23, 2022, by an out-of-network (OON) provider.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 70450 billed for date of service October 29, 
2022. 
 
You asked the Plan to pay for procedure code 70450. You say that the claim was billed correctly and should be 
paid. 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 October 29, 
2022.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to waive the cost share for Medicare Part B prescription drugs and a 
specialist office visit provided on July 7, 2022, to August 4, 2022. 
 
You asked the Plan to waive the cost share for Medicare Part B prescription drugs and a specialist office visit. 
You say that you disagree with the cost share. The Plan denied your request. The Plan says this cost sharing 
was charged correctly. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a 20% 
coinsurance for Medicare Part B prescription drugs and a $50 copayment for physician/practitioner 
services/specialist.  
 
You have been asked to pay a 20% coinsurance for Medicare Part B prescription drugs and a $50 copayment 
for a specialist office visit. This item/service falls within the Medicare Part B prescription drugs and physician/practitioner services/specialist benefit category. The total allowed amount for the prescription drugs 
is $4,835.10. You are being asked to pay $967.02 ($4,835.10 x 20% = $967.02). The total amount you are 
being asked to pay is $1,036.86 ($986.86 + $50 = $1036.86). 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 cost share 
for Medicare Part B prescription drugs and a specialist office visit provided on July 7, 2022, to August 4, 2022.
Appeal type: DME/ Orthotics
Decision: Favorable

 
We decided that the Plan has to pay for the FreeStyle Libre sensors (K0553) provided on November 16, 2022. 
 
You asked the Plan to pay for the diabetic supplies. You say that the enrollee needs these supplies every 30 
days. The Plan denied your request. The Plan says that the date of service is not supported. 
 
The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when there are both a 
physician order and proof of delivery.  
 
The record contains a valid physician order and proof of delivery which support medical necessity for the 
supplies provided in this case. Therefore, we decided that the Plan has to pay for the FreeStyle Libre sensors 
(K0553) provided on November 16, 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 formula by mouth. 
 
You asked the Plan to pre-approve formula by mouth. You say that this is your feeding supplement four time 
per day. The Plan denied your request. The Plan says formula by mouth is not a covered benefit. 
 
The Plan must follow Medicare rules. The rules say that Medicare does not pay for nutritional supplementation. 
 
The items you asked the Plan to pre-approve are considered nutritional supplements. Although these may be 
appropriate, neither Medicare nor the Plan provides coverage for them. Therefore, we decided that the Plan 
does not have to pre-approve formula by mouth.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a specialist office visit provided on July 7, 
2022. 
 
You asked the Plan to waive the copayment for an office visit. You say that the provider failed to disclose 
important information about a program at no cost to you that you are unable to take and now you are being 
charged with a specialist office visit. The Plan denied your request. The Plan says this cost sharing was charged 
correctly. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $25 
copayment per visit to a specialist.  
 
You have been asked to pay a $25 copayment for a specialist office visit. This item/service falls within the 
physician/practitioner services 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 
specialist office visit provided on July 7, 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 the services are medically necessary. The 
Plan denied your request. The Plan says massage therapy is not a covered benefit. 
 
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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a SPRINT peripheral nerve stimulator (PNS) system. 
 
You asked the Plan to pre-approve the SPRINT PNS. You say that this denial is incorrect as this procedure is a 
covered benefit under Medicare, and therefore, Medicare Advantage plans. The Plan denied your request. The 
Plan says the SPRINT peripheral nerve stimulator (PNS) system does not fit the Medicare definition of an 
implanted peripheral nerve stimulator. 
 
The Plan must follow Medicare rules. Medicare rules say that implantable peripheral nerve stimulators and 
central nervous system stimulators may be covered to treat chronic intractable pain.  
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the SPRINT PNS have not been met. Therefore, we decided that the Plan does not have to pre-
approve a SPRINT peripheral nerve stimulator (PNS) system.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a pneumatic compression device (E0652) and sleeves 
(E0656, E0667). 
 
You asked the Plan to pre-approve a pneumatic compression device. You say that the items are medically 
necessary. The Plan denied your request. The Plan says there is no documentation the member has 
lymphedema extending onto the chest, trunk and/or abdomen that extends past the limits of a standard 
compression sleeve, and the chest, trunk and/or abdominal lymphedema has failed to improve with a four-week 
trial. 
 
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. 
 
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 sleeves (E0656, E0667).