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

 
We decided that the Plan does not have to pay for transcutaneous electrical nerve stimulator (TENS) unit leads 
provided on August 1, 2022. 
 
You asked the Plan to pay for TENS supplies. You say that these supplies were delivered. The Plan denied 
your request. The Plan says an acceptable proof of delivery was not provided. 
 
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 a proof of delivery for the supplies provided in this case. The delivery form 
does not include evidence of delivery of the specific items billed on this claim to the enrollee. 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 transcutaneous electrical nerve stimulator (TENS) unit leads 
provided on August 1, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a shower chair. 
 
You asked the Plan to pay for a shower chair. You say that you would like to request reconsideration of the 
denied claim. The Plan denied your request. The Plan says this item is not covered by Medicare. 
 
The Plan must follow Medicare rules. Medicare rules say that shower chairs are not covered because they are 
not primarily medical in nature.  
 
While a shower chair may be appropriate in this case, neither the Plan nor Medicare offers coverage of this 
item. Therefore, we decided that the Plan does not have to pay for a shower chair.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an Over-Bed Table (E1399). 
 
You asked the Plan to pre-approve an Over-Bed Table. You say that you need this item due to your medical 
condition. The Plan denied your request. The Plan says this item is not medical in nature and is regularly and 
primarily used by persons who do not have a specific medical need for them. 
 
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a 
medical purpose.   
 
The item at issue in this appeal does not serve a purpose that is primarily medical in nature. This item is 
available to the general public and would be helpful even to those who are not sick or injured. Therefore, we 
decided that the Plan does not have to pre-approve an Over-Bed Table (E1399).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 64415 billed for date of service March 9, 
2021. 
 
You asked the Plan to pay for procedure code 64415. You say that the service is separately payable. The Plan 
denied your request. The Plan says payment for code 64415 is bundled into payment for code 01740. 
 
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 64415 is a column II code to column I code 01740. Code 64415 was 
billed with an XU modifier. The anesthesia service was provided during surgery to treat a right olecranon 
fracture. The records do not show that the anesthesia was an unusual non-overlapping service. 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 64415 billed for date of service March 9, 2021.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve continued skilled nursing facility (SNF) care from 
January 26, 2022, forward. 
 
You asked the Plan to pre-approve continued SNF care. You say that you would like your stay extended. The 
Plan denied your request. The Plan says continued SNF care is not medically necessary because you do not 
require skilled services to be performed by a nurse or physical therapist. 
 The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors 
listed in the Medicare rules section are met. Custodial care is not covered. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve continued SNF care. Our reviewer says 
that the requested SNF care is not considered medically reasonable and necessary based on Medicare 
guidelines. Our physician reviewer found that you do not have daily skilled nursing needs that require the 
specialized skill, knowledge, and judgment of a skilled professional nurse. You do not have daily skilled 
therapy needs that require the specialized skill, knowledge, and judgment of a skilled professional therapist. 
You do not require daily skilled nursing and/or skilled therapy on an inpatient basis in a skilled nursing facility 
(SNF) setting. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of continued SNF care have not been met. Therefore, we decided that the Plan 
does not have to pre-approve continued skilled nursing facility (SNF) care from January 26, 2022, forward.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Oncomine DX Target Test. 
 
You asked the Plan to pre-approve Oncomine DX Target Test. You say that you want the Plan to approve the 
testing. The Plan denied your request. The Plan says this test is not approved for prostate cancer. 
 
The Plan must follow Medicare rules. Medicare rules say that ThermoFisher Oncomine DX Target Test is for 
patients with Non-Small Cell Lung Cancer.  
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of Oncomine DX Target Test have not been met. According to the medical records the enrollee has 
not been diagnosed with non-small cell lung cancer. The rules say that ThermoFisher Oncomine DX Target 
Test is for patients with Non-Small Cell Lung Cancer (NSCLC). Therefore, we decided that the Plan does not 
have to pre-approve Oncomine DX Target Test.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an extended battery (E1399). 
 
You asked the Plan to pre-approve an extended battery. You say that you want to increase your time with 
activities away from home. The Plan denied your request. The Plan says this is not covered. 
 
The Plan must follow Medicare rules. The rules state that for equipment to be covered, it must be appropriate 
and needed for use inside the home.  
 
The item at issue in this appeal is for use outside of the home. Although this item may be helpful, neither 
Medicare nor the Plan covers equipment for use outside the home. Therefore, we decided that the Plan does not 
have to pre-approve an extended battery (E1399).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve infraumbilical panniculectomy, abdominoplasty, and 
excision of excessive skin (15830, 15839, 15847). 
 
You asked the Plan to pre-approve the services. You say that this is medically necessary. The Plan denied your 
request. The Plan says there is no documentation that the excess tissue is contributing to skin infections or 
intertrigo. 
 
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 services. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found that in this case, the record indicates that the enrollee has a pannus from previous panniculectomy 
following massive weight loss. The primary source record provided does not indicate that the enrollee has 
chronic intertrigo that is refractory to conservative medical treatment. The record provided does not establish 
the medical necessity and reasonableness, as defined by Medicare rules, of the requested service. The elements 
of the coverage criteria are not satisfied. 
 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 services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve infraumbilical panniculectomy, abdominoplasty, and excision of excessive skin (15830, 
15839, 15847).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the eye exam provided on October 3, 2022. 
 
You asked the Plan to waive the copayment for the eye exam. You say that this was your annual diabetes eye 
exam, which under the preventive care service benefit, is covered in full. 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 
copayment for each Medicare-covered eye exam to diagnose and treat diseases and conditions of the eye.  
 
You have been asked to pay a $20 copayment for the eye exam. This item/service falls within vision 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 eye exam provided on October 3, 2022.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care. 
 
You asked the Plan to pre-approve SNF care. You say that the enrollee needs SNF care. The Plan denied your 
request. The Plan says your request does not meet Medicare guidelines because you are receiving adequate and 
necessary physician supervision and rehabilitation in the current inpatient rehabilitation facility. 
 The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors 
listed in the Medicare rules section are met. Custodial care is not covered. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve SNF care. Our reviewer says that the 
requested SNF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found that the enrollee does not have daily skilled nursing needs that require the specialized 
skill, knowledge, and judgment of a skilled professional nurse. The enrollee does not have daily skilled therapy 
needs that require the specialized skill, knowledge, and judgment of a skilled professional therapist. The 
enrollee does not require daily skilled nursing and/or skilled therapy on an inpatient basis in a skilled nursing 
facility (SNF) setting. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of SNF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve skilled nursing facility (SNF) care.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for inpatient hospital services provided from February 16, 2022, 
to February 17, 2022, by an OON provider. 
 
You asked the Plan to pay for inpatient hospital services. You say that you would like reconsideration based on 
the records submitted. The Plan denied your request. The Plan says the inpatient hospital services were not 
medically necessary. 
 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 records do not show a pre-visit coverage decision was done to confirm that these services were medically 
necessary. 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 inpatient 
hospital services provided from February 16, 2022, to February 17, 2022, by an OON provider.
Appeal type: Testing
Decision: Favorable

 
We decided that the Plan has to pay for the duplex scan of extremity veins (93970) provided on August 16, 
2022. 
 
You asked the Plan to pay for the duplex scan of extremity veins. You say that due to an unsuccessful 
procedure with a previous provider in May 2022, it was necessary for an additional ultrasound to be used as a 
diagnostic tool to evaluate the enrollee's condition and plan of care. The Plan denied your request. The Plan 
says that this service does not meet the applicable coverage requirements. 
 
The Plan follows Medicare rules. Medicare rules say that non-invasive evaluation of extremity veins will be 
considered to be medically necessary when the patient has deep venous thrombophlebitis or has clinical 
findings which suggest the possibility of acute deep venous thrombophlebitis. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pay for the duplex scan of extremity veins. Our 
reviewer says that the documentation supports the medical necessity of the imaging study in question. Our 
physician reviewer found the enrollee presents with lifestyle limiting leg pain following an endovenous 
procedure. Our reviewer found that there is documentation of associated bulging varicosities. Our physician 
reviewer also found in this case, it was appropriate to obtain a lower extremity venous duplex examination to, 
among other things, rule out DVT. 
 
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 duplex scan of extremity veins have been met. Therefore, we decided that 
the Plan has to pay for the duplex scan of extremity veins (93970) provided on August 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 a Stationary Exercise Bike (E1399). 
 
You asked the Plan to pre-approve a Stationary Exercise Bike. You say that you would like this bike to be able 
to exercise without the fear of falling. The Plan denied your request. The Plan says this item is not considered 
medical in nature and primarily used by persons who do not have a specific medical need for them. 
 
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a 
medical purpose.   
 
The item at issue in this appeal does not serve a purpose that is primarily medical in nature. This item is 
available to the general public and would be helpful even to those who are not sick or injured. Therefore, we 
decided that the Plan does not have to pre-approve a Stationary Exercise Bike (E1399).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the genetic testing services provided on May 25, 2022. 
 
You asked the Plan to pay for the testing services. You say that the test offers a more complete view of cancer 
risks. The Plan denied your request. The Plan says the documentation does not support the testing. 
 
 
 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. The limited medical records from the treating physician do not show 
that the hereditary risk testing was not ordered for a specific medical problem. This testing is not covered for 
screening purposes. Based on this information, we decided that there is insufficient information in the record to 
determine if Medicare rules for coverage of the testing services have been met. . Therefore, we decided that the 
Plan does not have to pay for the genetic testing services provided on May 25, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the dialysis services provided from May 12, 2022, to May 
26, 2022. 
 
You asked the Plan to pay for the billed services. You say that the denial is unwarranted. The Plan denied your 
request. The Plan says an inappropriate diagnosis code was billed. 
 The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate code. 
 
We looked at the file and the rules. The claim billed procedure code 90999, indicating an ESRD claim. 
However, the claim was not billed with an ESRD diagnosis code. Based on this information, we decided that 
Medicare rules for coverage of the billed services have not been met. Therefore, we decided that the Plan does 
not have to pay for the dialysis services provided from May 12, 2022, to May 26, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to waive the cost-sharing for the continuous positive airway pressure 
(CPAP) equipment provided from June 30, 2022, to September 19, 2022. 
 
You asked the Plan to waive the cost-sharing for the continuous positive airway pressure (CPAP) equipment. 
You say that the cost-sharing should be lower. 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 in-network Medicare-covered equipment and supplies, which includes oxygen equipment. 
 
 
 
 
 You have been asked to pay a cost-share of $136.98 for the continuous positive airway pressure (CPAP) 
equipment ($684.95 allowed amount x .20 = $136.98 rounded down). These items/services fall within the 
durable medical equipment (DME) and related supplies benefit category. This means that you have been asked 
to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation 
you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive 
the cost-sharing for the continuous positive airway pressure (CPAP) equipment provided from June 30, 2022, 
to September 19, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. The Plan denied your request. The Plan says the records show that 
it is not reasonable to expect that you will fully benefit from the intensity of services of an IRF. Medically 
necessary care may be provided safely in a different level of care. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found the records show you have complex functional impairments and active medical comorbidities, however updated therapy notes do not show you would be able to tolerate 15hrs of therapy per 
week. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a Zynex NexWave device/supplies provided on July 14, 
2022. 
 
You asked the Plan to pay for electrical stimulator/supplies. You say that without these supplies the enrollee 
cannot continue treatment. The Plan denied your request. The Plan says proof of delivery has been provided. 
 
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 proof of delivery. The delivery form does not include evidence of delivery 
of the specific items billed on this claim to the enrollee. 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 Zynex NexWave device/supplies provided on July 14, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a metal substructure to acrylic full denture (D5876), an 
implant supported removable denture (D6111), and a semi-precision attachment (D6192) for tooth #23 and #26 
provided on June 20, 2022. 
 
You asked the Plan to pay for the dental services. You say that the code was inappropriately changed and that 
the services provided were appropriately billed as D5120. The Plan denied your request. The Plan says code 
D5120 was not supported by the medical records provided. The Plan says that dental services in dispute are not 
covered by Medicare or under this contract.  
 
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. 
 
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. 
 
We looked at the file and Medicare rules. Based on this information, we decided that there is insufficient 
information in the record to determine if the provider supplied a complete lower denture (D5120) on the date of 
service. The appellant did not supply documentation that supported a complete lower denture (D5120) that was 
provided on June 20, 2022. Though the Plan offers a dental benefit in excess of Medicare coverage, the 
services represented by codes D5876, D6111 and D6192 are not among those covered under this benefit. 
Therefore, we decided that the Plan does not have to pay for a metal substructure to acrylic full denture 
(D5876), an implant supported removable denture (D6111), and a semi-precision attachment (D6192) for tooth 
#23 and #26 provided on June 20, 2022.