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

 
We decided that the Plan does not have to pay for the fluoroscopy services provided on July 1, 2021. 
 
You asked the Plan to pay for the services provided. You say that the report clearly mentions the doctor has 
interpreted the reports. The Plan denied your request. The Plan says the code is not separately reimbursed. 
 
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 76000 is Fluoroscopy (separate procedure), up to 1 hour 
physician or other qualified health care professional time. We find that CPT code 76000 is not supported in the 
medical record. Specifically, the records show that the enrollee received a portable chest x-ray. The records do 
not indicate that the enrollee received continuous real-time imaging.  Based on this information, we decided that Medicare rules for coverage of the services provided have not been 
met. Therefore, we decided that the Plan does not have to pay for the fluoroscopy services provided on July 1, 
2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the lab testing provided on February 21, 2021. 
 
You asked the Plan to pay for the lab services. You say that the testing provides the most up-to-date treatment 
options. The Plan denied your request. The Plan says the billed codes cannot be verified. 
 
 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. 
 
The file shows the enrollee received a Tempus gene panel. We looked at the file and Medicare rules. In this 
case, the claim was billed with the laboratory POS code. The records do not support that the sample was taken 
in a laboratory setting. Based on this information, we decided that Medicare rules for coverage of the lab 
services have not been met. Therefore, we decided that the Plan does not have to pay for the lab testing 
provided on February 21, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a pneumatic compression device (E0675). 
 
You asked the Plan to pay for a pneumatic compression device. You say that you would like reconsideration 
because the pneumatic compression device is medically necessary. The Plan denied your request. The Plan says 
this is not a covered benefit. 
 
The Plan follows Medicare rules. The rules state that a PCD that provides intermittent limb compression for the 
purpose of prevention of venous thromboembolism (E0676) is a preventive service. The rules also say that a 
PCD coded as E0675 to treat peripheral arterial disease is not eligible for reimbursement. 
 
We looked at the file and Medicare rules. Based on this information we decided that Medicare rules for 
coverage of the PCD have not been met. Specifically, this item is not a covered benefit of Medicare or the Plan. 
PCDs are not covered for preventions of venous thromboembolism nor for treatment of peripheral artery disease, regardless of how they are billed on the claim. Therefore, we decided that the Plan does not have to 
pay for a pneumatic compression device (E0675).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home health visits provided on January 19, 2022, and 
January 26, 2022, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for the home health visits. You say that it is the facilities responsibility to obtain 
prior authorization and the services were rendered in good faith. The Plan denied your request. The Plan says 
the rendering provider is an out-of-network 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 the home health visits provided on January 19, 
2022, and January 26, 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 imaging services provided on April 24, 2021. 
 
You asked the Plan to pay for the imaging services. You say that the enrollee was not enrolled in hospice on 
the date of service in this case. 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 imaging services provided on April 24, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the percutaneous transluminal coronary angioplasty (92921) 
provided on November 18, 2021. 
 
You asked the Plan to pay for the percutaneous transluminal coronary angioplasty (92921). You say that the 
attached medical records should be reviewed, and the claim processed accordingly. The Plan denied your 
request. The Plan says bundled services are not eligible for separate payment. 
  The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
We find that CPT code 92921 has a status indicator of B on the Physician Fee Schedule. This means that CPT 
code 92921 is not separately payable. Based on this information, we decided that Medicare rules for coverage 
of the percutaneous transluminal coronary angioplasty (92921) have not been met. Therefore, we decided that 
the Plan does not have to pay for the percutaneous transluminal coronary angioplasty (92921) provided on 
November 18, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the diabetic testing supplies rendered on March 11, 2020. 
 
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says the services are not from the preferred provider. 
 
The Plan must follow Medicare rules. Medicare rules say that Plans may limit enrollees to preferred providers 
for durable medical equipment and supplies.  
 
We looked at the file and Medicare rules. The items were from a non-preferred provider. The services were 
available from one of the Plans preferred providers. Based on this information, we decided that Medicare rules 
for coverage of these services have not been met. Therefore, we decided that the Plan does not have to pay for 
the diabetic testing supplies rendered on March 11, 2020.
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. You say that IRF care is medically reasonable and necessary for 
the enrollee's condition. The Plan denied your request. The Plan says rules for IRF care have not been met. 
 
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 that the patient has a past medical history of hypertension, hyperlipidemia and 
neuropathy and is living at home receiving care for lymphedema of the legs and candidiasis of the skin.  There are no medical problems for which inpatient medical care has been recommended. There are no complex 
nursing or rehabilitation needs. The patient does not require treatment by multiple therapies, including either 
physical therapy or occupational therapy, and an intensive rehabilitation therapy program. While the patient has 
a need for physical and/or occupational therapy, there is no documentation of a need for an intensive 
rehabilitation program. There is not a reasonable expectation that this patient will be able to fully participate in 
and benefit from the intensive rehabilitation therapy program provided in an IRF. 
 
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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the chiropractic services provided from 
July 09, 2021 to September 02, 2021. 
 
You asked the Plan to waive the copayment for chiropractic services. You say that you paid out of pocket for 
chiropractic services, and you would like to be reimbursed. The Plan denied your request. The Plan says the 
claims reprocessed to apply a $20 copayment for each date of service at issue. 
 
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 $20 
copayment for Medicare covered chiropractic services.  
  You have been asked to pay $80 for chiropractic services ($20/visit x 4 = $80). The chiropractic services fall 
within the Chiropractic 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 
the chiropractic services provided from July 09, 2021 to September 02, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the lab services provided on August 31, 2021. 
 
You asked the Plan to pay for the services provided. The Plan denied your request. The Plan says the billed 
codes cannot be verified. 
 
 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. The claim in this case was billed with the laboratory POS code. The 
records do not support that the sample was taken in a laboratory setting. Based on this information, we decided 
that Medicare rules for coverage of the services provided have not been met. Therefore, we decided that the 
Plan does not have to pay for the lab services provided on August 31, 2021.
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 December 20, 
2021, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for a domiciliary or rest home visit. You say that this provider was not responsible to 
obtain authorization, and the assisted living facility is responsible to obtain prior authorization for all of their 
patients. The Plan denied your request. The Plan says this provider is out-of-network with the Plan, and 
authorization was not obtained prior to the services being rendered. 
 
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 
December 20, 2021, by an out-of-network (OON) provider.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve transthoracic echocardiography (TTE) testing. 
 
You asked the Plan to pre-approve TTE testing. You say that you are appealing with supporting records. The 
Plan denied your request. The Plan says the denial of authorization for this service is correct, because TTE 
without new clinical signs or symptoms 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.  
 
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 TTE testing. Our reviewer says that the 
requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found clinical guidelines do not support repeating TTE with no intervening change in clinical status or 
physical findings. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of TTE testing have not been met. Therefore, we decided that the Plan does not 
have to pre-approve transthoracic echocardiography (TTE) testing.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an upright walker (E1399). 
 
You asked the Plan to pre-approve an upright walker. You say that the item is medically necessary. The Plan 
denied your request. The Plan says the item is not medically necessary. 
 The Plan follows Medicare rules. Medicare rules say that if all of the criteria are not met, the walker will be 
denied as not reasonable and necessary. 
 
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 an upright walker. Our reviewer says 
that this item is not medically necessary. Our physician reviewer found the records do not clarify that the 
enrollee's functional mobility deficit can be sufficiently resolved with use of the requested walker. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of an upright walker have not been met. Therefore, we decided that the Plan does 
not have to pre-approve an upright walker (E1399).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for laboratory services provided on December 
22, 2021. 
 
You asked the Plan to waive the copayment for the laboratory services. You say that your doctor did not inform 
you there would be a 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 a $25 
copayment for lab services performed in an outpatient hospital facility.  
 
You have been asked to pay a $25 copayment for the laboratory services. The laboratory services fall within 
the Outpatient Diagnostic Tests and Therapeutic Services and 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 copayment for laboratory services provided on December 22, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the L300 Go System and L300 Go Thigh Plus System 
(E0770 and E1399). 
 
You asked the Plan to pre-approve the L300 Go System and L300 Go Thigh Plus System. You say that the 
items are medically necessary. The Plan denied your request. The Plan says the items are not medically 
necessary. 
 
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 L300 Go System and L300 Go 
Thigh Plus System. Our reviewer says that the requested items are not considered medically reasonable and 
necessary in this case. Our physician reviewer found the records do not document the enrollee has disuse 
atrophy where nerve supply to the muscle is intact, including brain, spinal cord and peripheral nerves, or other 
non-neurological reasons for disuse atrophy. 
 
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 L300 Go System and L300 Go Thigh Plus System have not been met. Therefore, we decided that the Plan does not have to pre-approve the L300 Go System and L300 Go Thigh Plus 
System (E0770 and E1399).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for foot orthotics provided on August 19, 2021. 
 
You asked the Plan to pay for foot orthotics. The Plan denied your request. The Plan says this item is not a 
covered benefit. 
 
Medicare rules state that supportive devices for the feet (such as orthotics) are only covered for patients with 
diabetic foot disease or for patients who wear a leg brace. The Plan follows these same rules.   
 
Records show that you do not suffer from diabetic foot disease, and you do not wear a leg brace. Although 
orthotics may be appropriate for you, neither Medicare nor the Plan provides coverage of orthotics for your 
condition. Therefore, we decided that the Plan does not have to pay for foot orthotics provided on August 19, 
2021.
Appeal type: Hospice
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ambulance service, basic life support, non-emergency 
transport (A0428), and ground mileage (A0425) provided on March 5, 2021. 
 
You asked the Plan to pay for the ambulance services. You say that the hospice election was not made until 
after the ambulance transport took place. 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 ambulance service, basic life support, non-emergency 
transport (A0428), and ground mileage (A0425) provided on March 5, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve pneumatic compression device (E0652) and garments 
(E0667) to be provided by an out-of-network (OON) provider. 
 
You asked the Plan to pre-approve the pneumatic compression device and garments. You say that you are the 
manufacturer and only supplier of the Flexitouch pneumatic compression device. This device prescribed for the 
enrollee cannot be obtained through the Plan's in-network provider. The Plan denied your request. The Plan 
says enrollees must receive their medical services from an in-network provider with the exception being 
urgent or emergent services. Non-emergent services with non-contracted providers require prior authorization 
before services being rendered. 
 
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 pre-approve care from out-of-network providers only in cases involving 
emergencies, out of area urgent care and care that cannot be provided by network providers. 
 
The requested provider in this case is not a network provider with the Plan. The Plan has network providers 
available who can provide the items/services at issue in this appeal. We found no exception that would require 
the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve pneumatic compression device (E0652) and 
garments (E0667) to be provided by an out-of-network (OON) provider.