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

 
We decided that the Plan does not have to pay for the arm sling (E1399) provided July 8, 2021 to July 12, 
2021. 
 
You asked the Plan to pay for the arm sling. You say that the arm slings are not disposable and they should be 
covered. You were told by several representatives that they were covered. The Plan denied your request. The 
Plan says disposable items are not covered. 
 
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 does not contain a valid physician order or relevant medical records which support medical 
necessity for the supplies provided in this case. Specifically, the physician orders, prescription and proof of 
payment was requested. 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 the arm sling (E1399) provided July 8, 2021 to 
July 12, 2021.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pay for therapeutic exercises, therapeutic activities, and therapeutic 
procedures provided on January 27, 2022, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for therapeutic exercises, therapeutic activities, and therapeutic procedures. You say 
that the denials do not acknowledge the medical necessity of the medical services provider, and the doctor's 
approval of the rehabilitation services was obtained as evidenced by the Plan's doctor request. The Plan denied 
your request. The Plan says the provider is out-of-network, and the services were not urgent/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 therapeutic exercises, therapeutic activities, and 
therapeutic procedures provided on January 27, 2022, by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the interrogation device evaluation (93294) rendered by the 
out-of-network (OON) provider on January 21, 2022. 
 
You asked the Plan to pay for this service. You say that you are requesting a reconsideration of the Plan's 
denial for payment. The Plan denied your request. The Plan says the service was rendered by an out of network 
provider, 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 provider in this case is not a network provider with the Plan. The Plan had network providers available 
who could have provided the service at issue in this appeal. The Plan did not pre-approve the service at issue. We found no exception that would require the Plan to pay for this service. Therefore, we decided that the Plan 
does not have to pay for the interrogation device evaluation (93294) rendered by the out-of-network (OON) 
provider on January 21, 2022.
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to hold you harmless for a comprehensive preventive evaluation (99397) provided 
on August 17, 2021. 
 
You asked the Plan to hold you harmless for the comprehensive preventive evaluation. You say that this was an 
annual health maintenance visit and should be covered as it has in the past. The Plan denied your request. The 
Plan says that a comprehensive preventive evaluation (99397) is not a covered benefit. 
 
Medicare rules say that a contract provider is an agent of the plan. Services and referrals given by a contract 
provider are considered approved by the plan unless notice is provided that the services will not be covered. 
The Plan follows these rules. 
 
You were referred for the comprehensive preventive evaluation by a contract provider. The file does not show 
that the Plan provided notice that the comprehensive preventive evaluation would not be covered prior to the 
services being rendered. Therefore, we decided that the Plan has to hold you harmless for a comprehensive 
preventive evaluation (99397) provided on August 17, 2021.  
 
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again 
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake 
and/or send us the new information. This does not happen often. If we decide to open the case again, we will 
send you a letter.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for a specialist office visit provided on August 
25, 2021. 
 
You asked the Plan to waive the coinsurance for a specialist office visit. You say that you saw your primary 
care physician and there should be no copayment. 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 30% 
coinsurance for an out-of-network specialist office visit.  
 The record shows the provider you saw is considered a family medicine specialist. You have been asked to pay 
$53.68, which is 30% coinsurance of the allowed amount for a specialist office visit ($178.93 allowed amount 
x 30% coinsurance = $53.68). A specialist office visit falls within the Physician/Practitioner Services, 
Including Doctors Office Visits benefit category. This means that you have been asked to pay the correct 
amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay 
when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the coinsurance for a 
specialist office visit provided on August 25, 2021.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve OneTouch Verio test strips for the enrollee. 
 
You asked the Plan to pre-approve OneTouch Verio test strips. You say that these are medically necessary for 
the enrollee. The Plan denied your request. The Plan says that they have not been given medical reasons 
indicating our preferred systems have failed or are contraindicated. 
 
The Plan must follow Medicare rules. Medicare rules say that the physician or treating practitioner must 
document in the beneficiarys medical record the reason why the specific brand or mode of delivery is 
necessary to avoid an adverse medical outcome. 
 
 
 
 
 
 
 
 
 We looked at the file and Medicare rules. The file does not include any documentation why the enrollee 
requires this specific brand of test strips. Without this, medical necessity cannot be established. Therefore, we 
decided that the Plan does not have to pre-approve OneTouch Verio test strips for the enrollee.
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 records provided support the need for 
LTACH care. The Plan denied your request. The Plan says the enrollee does not meet the guidelines for 
LTACH care. The Plan says that the enrollee can safely receive the care needed in another setting. 
 
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 enrollee was admitted to the acute care hospital with acute respiratory failure, 
chronic open wounds, sepsis/pneumonia requiring IV antibiotics, wound care, and BiPAP support. Recent 
notes describe the enrollee as tolerating low dose oxygen during the day and BiPAP at night and only requiring uncomplicated wound care with antibiotic course completed and vitals now stable. The enrollee appears to be 
more stable and improving and should only require short-term additional acute care services that can be 
completed at the current facility until more appropriate for a lower level of care. The enrollee does not require 
services at the LTACH that are not already available at the current facility. Transfer to an LTACH is not 
medically necessary as it would not be clinically advantageous at this time. Completion of care at the current 
facility is recommended. 
 
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 pre-approve high strength, lightweight wheelchair (CPT code 
K0004), elevating leg rests, pair (CPT code K0195) and anti-tipping device (CPT code E0971). 
 
You asked the Plan to pre-approve the DME. You say that the wheelchair is a medical necessity because you 
are unable to walk. The Plan denied your request. The Plan says there is no documentation in the records to 
support the need for this DME. 
 
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 documentation does not support that you have a mobility limitation that significantly impairs your 
ability to participate in one or more mobility-related activities of daily living (MRADLs) such as toileting, 
feeding, dressing, grooming, and bathing in customary locations in the home. The documentation does not 
support that your mobility limitation cannot be sufficiently resolved by the use of an appropriately fitted cane 
or walker or that your home provides adequate access between rooms, maneuvering space, and surfaces for use 
of the manual wheelchair that is requested. The documentation does not support that the use of a manual 
wheelchair will significantly improve your ability to participate in MRADLs and you will use it on a regular 
basis in the home. There are no specific objective exam findings of detailed muscle strength grades, endurance, 
range of motion, or coordination, presence of pain, or deformity or absence of one or both upper and lower 
extremities. There is no evidence that a high strength lightweight wheelchair (K0004) is needed as there is no 
evidence that the patient is unable to engage in activities in the home that cannot be performed in a standard or 
lightweight wheelchair. The documentation does not support that you require a seat width, depth, or height that 
cannot be accommodated in a standard, lightweight or hemi-wheelchair, and spends at least two hours per day 
in the wheelchair. There is no evidence that you have leg edema, contractures in the lower extremities, inability 
to flex your knees to 90 degrees, or meets the criteria for a reclining back on a wheelchair. As the requested 
wheelchair is not medically necessary the accessories of anti-tippers are not medically necessary. The criteria per LCD L33788 have not been met for high strength, lightweight wheelchair (CPT code K0004), elevating leg 
rests, pair (CPT code K0195), and anti-tipping device (CPT code E0971). 
 
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 high strength, lightweight wheelchair (CPT code K0004), elevating leg rests, pair (CPT code 
K0195) and anti-tipping device (CPT code E0971).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for neuromuscular reeducation of movement, balance, 
coordination, kinesthetic sense, posture, and/or proprioception for sitting and/or standing activities, 
vasopneumatic device, Hydration, Therapeutic, Prophylactic, Diagnostic Injections, Infusions, Electrical 
Stimulation, vitamin injections and subcutaneous injection of FDA Nutri-Pharmaceutical blend provided from 
September 14, 2020, through November 11, 2020. 
 
You asked the Plan to pay for neuromuscular reeducation of movement, balance, coordination, kinesthetic 
sense, posture, and/or proprioception for sitting and/or standing activities, vasopneumatic device, Hydration, 
Therapeutic, Prophylactic, Diagnostic Injections, Infusions, Electrical Stimulation, vitamin injections and 
subcutaneous injection of FDA Nutri-Pharmaceutical blend. You say that the services are medically necessary. 
The Plan denied your request. The Plan says that the denial of Sanexas neoGen-Series Therapy (electrical cell 
stimulation), vasopneumatic device therapy, and the associated codes for the subcutaneous injection of FDA 
Nutri-Pharmaceutical blend was appropriate given the clinical scenario and the guidance. 
 
The Plan must follow Medicare rules. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of neuromuscular reeducation of movement, balance, coordination, kinesthetic sense, posture, and/or 
proprioception for sitting and/or standing activities, vasopneumatic device, Hydration, Therapeutic, 
Prophylactic, Diagnostic Injections, Infusions, Electrical Stimulation, vitamin injections and subcutaneous 
injection of FDA Nutri-Pharmaceutical blend have not been met. Therefore, we decided that the Plan does not 
have to pay for neuromuscular reeducation of movement, balance, coordination, kinesthetic sense, posture, 
and/or proprioception for sitting and/or standing activities, vasopneumatic device, Hydration, Therapeutic, 
Prophylactic, Diagnostic Injections, Infusions, Electrical Stimulation, vitamin injections and subcutaneous 
injection of FDA Nutri-Pharmaceutical blend provided from September 14, 2020, through November 11, 2020.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for laboratory services (80053, 80061, 82306, 82607, 82728, 
82746, 83036, 83090, 83540, 83550, 83970, 84439, 84443, 84480, 84481, 84550, 85025, 85651, 86003, 86141, 
86431, 86780) provided on June 23, 2021. 
 
You asked the Plan to pay for laboratory services. You say that this should be covered. The Plan denied your 
request. The Plan says this was not billed correctly. 
 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 laboratory 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 laboratory services (80053, 80061, 82306, 82607, 82728, 82746, 83036, 
83090, 83540, 83550, 83970, 84439, 84443, 84480, 84481, 84550, 85025, 85651, 86003, 86141, 86431, 
86780) provided on June 23, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve continued inpatient psychiatric hospital care. 
 
You asked the Plan to pre-approve continued inpatient psychiatric hospital care. You say that the requested 
continued inpatient psychiatric hospital care is medically necessary. The Plan denied your request. The Plan 
says the requested continued inpatient psychiatric hospital care does not meet criteria. 
 
The Plan must follow Medicare rules. The rules say that inpatient psychiatric services may be covered if the 
patient requires active treatment.  
 
 
 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 continued inpatient psychiatric hospital 
care. Our reviewer says that the service is not medically necessary. Our physician reviewer found it did not 
appear that active treatment was taking place beyond the date in question. It did not appear that the services 
were reasonably expected to improve your condition or for the purpose of diagnosis beyond the date in 
question. Based upon review, the records provided for your admission do not meet the criteria for June 6, 2022, 
forward as you were not shown to be a danger to herself or others, delusions, auditory or visual hallucinations 
noted. You were cooperative/compliant with treatment while not showing any threats the safety. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of continued inpatient psychiatric hospital care have not been met. Therefore, we 
decided that the Plan does not have to pre-approve continued inpatient psychiatric hospital care.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve transurethral destruction of prostate tissue; by 
radiofrequency generated water vapor thermotherapy (CPT code 53854). 
 
You asked the Plan to pre-approve the service. You say that the service is medically necessary. The Plan 
denied your request. The Plan says Rezum should only be done on prostate size between 30-80 grams. The 
Plan states there is documentation that the enrollee's prostate is 180 grams. The Plan states there is no peer 
reviewed literature that supports Rezum for a prostate this size. 
 
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 service. Our reviewer says that the 
requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found the Rezum procedure is not medically reasonable and necessary in this case. AUA Guideline 
states that The Rezum System is indicated for men 50 years and older with a prostate volume of greater than or 
equal to 30cm3 and less than or equal to 80cm3. The records show that the prostate is 137 cc. 
 
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 transurethral destruction of prostate tissue; by radiofrequency generated water vapor 
thermotherapy (CPT code 53854).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for contact lenses purchased on January 17, 2022. 
  You asked the Plan to pay for contact lenses. You say that this was the first time you attempted to buy contacts 
and you would not have completed this purchase if you were aware it was outside of your coverage. You say 
that you are on a very low income and do not have funds to pay for the contact lenses at this time. The Plan 
denied your request. The Plan says your eyeglasses were paid for therefore contacts would not be covered. 
 
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 contact lenses instead of lenses and frames every 2 years. 
 
We looked at the file and the Plan's rules. Based on this information, we decided that the Plan's rules for 
coverage of contact lenses have not been met. Specifically, the claim for the glasses purchased on January 18, 
2022, was received prior to this claim and was paid, which exhausted your benefit. Therefore, we decided that 
the Plan does not have to pay for contact lenses purchased on January 17, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for electrocardiogram, routine ECG with at least 12-leads; 
interpretation and report only (93010) provided September 4, 2021. 
 
You asked the Plan to pay for the diagnostic service. You say that your doctor provided quality care for the 
enrollee and it is only fair he receives proper compensation for treatment. The Plan denied your request. The 
Plan says the service is not supported without required documentation. The plan did not receive primary 
carriers Explanation of Benefits. 
 
The Plan must follow Medicare rules. The rules state that Medicare plans are considered secondary insurers 
when an enrollee has another type of insurance. This means that the Plan is not responsible for paying for services until the claim for those services has gone to the primary insurer. However, plans are still required to 
coordinate their benefits with the primary insurers. Plans can coordinate their benefits with the primary insurers 
in three ways. First, the Plan can send the bill directly to the primary insurer for payment. Second, the Plan can 
direct the provider to send the bill to the primary insurer. Third, the Plan can pay for the services and submit a 
bill for reimbursement to the primary insurer. 
 
The Plan has met its obligation with regards to coordination of benefits. Specifically, the Plan has another 
insurance carrier as the primary insurer. As the secondary insurer, the Plan cannot be held responsible for the 
diagnostic service until the primary insurer has denied the claim for these services. Therefore, we decided that 
the Plan does not have to pay for electrocardiogram, routine ECG with at least 12-leads; interpretation and 
report only (93010) provided September 4, 2021.