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

 
We decided that the Plan does not have to pay for a total electric hospital bed with mattress, over-bed table, 
non-covered item, and sales tax received on September 27, 2021 to October 9, 2021. 
 
You asked the Plan to pay for a total electric hospital bed with mattress, over-bed table, non-covered item, and 
sales tax. You say that you feel the Plan should pay for these items. The Plan denied your request. The Plan 
says the items received are not covered. 
 
The Plan must follow Medicare rules. Medicare rules say that a total electric hospital bed is not covered. The 
rules say that for equipment to be covered, it must primarily serve a medical purpose. The rules also say that 
sales tax is not payable. 
 
While a total electric hospital bed may be appropriate in this case, neither the Plan nor Medicare offers 
coverage for this item. The over-bed table 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. The non-covered item, and sales tax are both non-payable. Therefore, we decided that the Plan 
does not have to pay for a total electric hospital bed with mattress, over-bed table, non-covered item, and sales 
tax received on September 27, 2021 to October 9, 2021.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for Home Health Services provided on July 10, 2021 to August 
8, 2021 by an out-of-network (OON) provider. 
 
You asked the Plan to pay for Home Health Services. You say that you believe you were given the wrong 
information and that you would like to appeal the denial of the claim. The Plan denied your request. The Plan 
says the referring provider and servicing provider are OON and it was determined these services can be 
received in-network. 
 
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 Home Health Services provided on July 10, 2021 
to August 8, 2021 by an out-of-network (OON) provider.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for revascularization services (procedure code 37225) provided 
to the enrollee on December 13, 2021. 
 
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. 
The Plan says the records do not support the services billed. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
In this case, the CPT Code Manual definition of code 37225 is "Revascularization, endovascular, open or 
percutaneous, femoral, popliteal artery(s), unilateral; with atherectomy, includes angioplasty within the same 
vessel, when performed." 
 
We asked our coder to carefully review the case file and apply the relevant Medicare rules to determine if the 
Plan was correct in denying the request to pay for the services. Our reviewer says that the services at issue in 
this case were not supported by the medical records. Our reviewer found the documentation does not support 
coverage of the code in question. The documentation is clear that the superficial femoral artery could not be 
traversed with a wire and could not be treated. Attempted, but not performed, procedures are not covered.  
We looked at this coder'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 pay for revascularization services (procedure code 37225) provided to the enrollee on December 13, 
2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for drug testing provided on September 21, 2021. 
 
You asked the Plan to pay for the drug testing. You say that you would like the plan to reconsider their denial. 
The Plan denied your request. The Plan says the services are not payable as billed. 
 
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 the drug testing 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 drug testing provided on September 21, 2021.
Appeal type: DME/ Orthotics
Decision: Favorable

 
We decided that the Plan has to pre-approve a replacement K3 foot and ankle system (L5981, L5988). 
 
You asked the Plan to pre-approve a replacement K3 foot and ankle system. You say that this replacement 
equipment is medically necessary. The Plan denied your request. The Plan says that you do not require 
replacement equipment with K3 functional level ankle-foot component. 
 
The Plan follows Medicare rules. Medicare rules say that a flex-walk system or equivalent (L5981, L5988) 
require a functional level of K3 or above. 
 
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 a replacement K3 foot and ankle 
system. Our reviewer says that the requested items are medically reasonable and necessary for the enrollee's 
condition. Our physician reviewer found you are a 61-year-old male with past medical history of right below 
the knee amputation previously using a K2 prosthesis. In this case, the clinical records show that patient is now 
a K3 level ambulator requiring a prosthesis that would assist with ambulation on variable terrain and steps. 
Therefore, the K3 foot and ankle system prosthetics (L5981, L5988) are medically necessary. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of a replacement K3 foot and ankle system have been met. Therefore, we decided 
that the Plan has to pre-approve a replacement K3 foot and ankle system (L5981, L5988).  
 
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: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve pembrolizumab. 
 
You asked the Plan to pre-approve pembrolizumab. You say that this is medically necessary. The Plan denied 
your request. The Plan says the records are not sufficient to show this is necessary. 
 
The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for anti-cancer 
drugs if they are medically accepted as safe and effective or appropriate for the particular use.  
 
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 pembrolizumab. Our reviewer says that 
the requested use of pembrolizumab is not supported Our physician reviewer found the record indicates that the 
enrollee has a diagnosis of  stage IV colon cancer that does not exhibit microsatellite instability/high (MSI-
H)/mismatch repair deficient (dMMR) tumor characteristics. The Food and Drug Administration has not stated 
that the requested drug is indicated for the enrollee's condition. The Medicare approved cancer drug compendia 
also do not contain a supportive citation for the use of the requested drug in the enrollee's clinical situation. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of pembrolizumab have not been met. Therefore, we decided that the Plan does not 
have to pre-approve pembrolizumab.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit provided on January 20, 2022 by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for an office visit. You say that you would like to request reconsideration of the 
denied claim. The Plan denied your request. The Plan says the provider is out-of-network and it was 
determined these services can be received in-network. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The requested provider in this case is not a network provider with the Plan. The Plan had network providers 
available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the 
item/service at issue. We found no exception that would require the Plan to pay for these items/services. 
Therefore, we decided that the Plan does not have to pay for an office visit provided on January 20, 2022 by an 
out-of-network (OON) provider.
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 requested admission to a LTACH is 
medically necessary. The Plan denied your request. The Plan says the requested admission to a LTACH does 
not meet criteria. 
 
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 still requires acute care services she is not clinically stable. The enrollee 
continues to receive acute care services, and these have not been denied. The medical record does not indicate 
that the enrollee requires services that she is not currently receiving but that would be available at the LTACH 
facility. 
 
 
 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 a MyoPro Motion G device. 
 
You asked the Plan to pre-approve a MyoPro Motion G device. You say that this item is medically necessary 
for the enrollee's condition. The Plan denied your request. The Plan says this requested device has not been 
shown to be better than standard ways to treat this condition. 
 
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 a MyoPro Motion G device. Our 
reviewer says that the requested items/services are not considered medically reasonable and necessary in this 
case. Our physician reviewer found the enrollee is a 63-year-old female with past medical history of 
cerebrovascular accident with right sided weakness. In this case, the clinical records from the provider state 
that patient requires this myoelectric orthosis for independent activities of daily living but there is no 
documentation to show that patient is not able to complete any specific activities of daily living with a simpler 
orthosis or why this myoelectric orthosis is required. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of a MyoPro Motion G device have not been met. Therefore, we decided that the 
Plan does not have to pre-approve a MyoPro Motion G device.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for magnetic resonance imaging (MRI) 
provided on November 1, 2021. 
 
You asked the Plan to waive the copayment for MRI. You say that this charge should be covered. The Plan 
denied your request. The Plan says the copayment applied is correct. 
 
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 $200 
copayment per provider, per date of service for complex radiology.  
 
You have been asked to pay $200 copayment for an MRI. MRIs 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 
MRI provided on November 1, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for intraoperative neuromonitoring (95937, 95941, 95822) 
provided December 4, 2020. 
 
You asked the Plan to pay for the intraoperative neuromonitoring. You say that these services were medically 
necessary. The Plan denied your request. The Plan says the records do not support the billed services. 
 
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 asked our coder to carefully review the case file and apply the relevant Medicare rules to determine if the 
Plan was correct in denying the request to pay for the intraoperative neuromonitoring. Our reviewer says that 
the codes billed are not supported. Our reviewer found the patient is noted to have undergone a selective nerve 
root block and L4-L5. This is not a clinical condition for which the use of intraoperative neuromonitoring is 
readily supported. Code 95941 is not supported in the medical literature. Train-of-four monitoring is bundled 
with the intraoperative neuromonitoring of electromyography (EMG) or motor evoked potentials (MEP) and, 
therefore, is not separately reportable. Code 95937 is not separately reportable. There was no evidence that a formal clinical diagnostic EEG was performed. Code 95822 is not supported by the records. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the intraoperative neuromonitoring have not been met. Therefore, we decided 
that the Plan does not have to pay for intraoperative neuromonitoring (95937, 95941, 95822) provided 
December 4, 2020.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the Guardant360 testing rendered on February 16, 2022. 
 
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 claim has not been processed by the primary insurer. 
 
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 made several 
attempts to obtain the Explanation of Benefits (EOB) for this claim from the primary insurer. As the secondary 
insurer, the Plan cannot be held responsible for these services until the primary insurer has denied the claim for 
these services. Therefore, we decided that the Plan does not have to pay for the Guardant360 testing rendered 
on February 16, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the hearing aid fitting/checking (V5011) and hearing aid 
(V5261) provided on January 4, 2022 by a non-participating provider. 
 
You asked the Plan to pay for the hearing aid fitting/checking and hearing aid. You say that you would have 
followed a different course had you been aware of the consequences. The Plan denied your request. The Plan 
says there is no coverage if hearing aids, or related services are received from a provider not part of the Plans 
hearing aid vendor network. The Plan also says that the hearing benefit is not covered if the services are not 
registered in advanced. 
 
Medicare does not pay for hearing aids or related services. However, the Plan offers a hearing aid benefit that 
exceeds Medicare coverage. For that reason, the plans coverage rules apply in this case. The Plan pays for 
hearing aids only when the services are rendered by the Plan's hearing aid vendor.  
 
 
 
 
 
 
 
 
 We looked at the file and the Plan's rules. Based on this information, we decided that the Plan's rules for 
coverage of the hearing aid fitting/checking, and hearing aid have not been met. Therefore, we decided that the 
Plan does not have to pay for the hearing aid fitting/checking (V5011) and hearing aid (V5261) provided on 
January 4, 2022 by a non-participating provider.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an emergency room (ER) visit provided on 
August 18, 2021. 
 
You asked the Plan to waive the copayment for the ER visit. You say that you cannot afford the 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 $90 
copayment for each emergency room visit.  
 
 
 
 
 
 
 
 You have been asked to pay a $90 copayment for the ER visit. The ER visit 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 an emergency room (ER) visit 
provided on August 18, 2021.
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pay for anesthesia services (01400) provided on November 12, 2021. 
 
You asked the Plan to pay for anesthesia services. You say that the services at issue were a medical necessity 
for the enrollee. The Plan denied your request. The Plan says that rules for payment have not been met. 
 
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and 
diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or 
payment. 
 
The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their 
decision to deny your request. Specifically, the Plan denied on the basis that the primary procedure was not 
pre-approved and is experimental/investigational. Medical records to determine the medical necessity of the 
primary procedure have not been provided. It is the Plan's responsibility to substantiate its denial. In this case, 
the denial has not been substantiated so we must find in your favor. Therefore, we decided that the Plan has to 
pay for anesthesia services (01400) provided on November 12, 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: Favorable

 
We decided that the Plan has to pay for the subsequent hospital care (99232) provided December 15, 2021 
 
You asked the Plan to pay for the hospital services. You say that please find the medical records attached for 
the claim for date of service 12/15/2021. The Plan denied your request. The Plan says that procedure exceeds 
maximum number of services allowed for a single date of service. 
 
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and 
diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or 
payment. 
 
The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their 
decision to deny your request. the Plan has not substantiated their reason to continue to deny. The Plan's denied 
this claim for exceeding maximum number of services allowed for a single date of service. The Explanation of 
Benefits provided dated 01/13/2022 shows only one unit of 99232 has been billed. No other Explanation of 
Benefits was provided in the case file showing that this claim has either been paid by the Plan or another valid 
denial. Therefore, we decided that the Plan has to pay for the subsequent hospital care (99232) provided 
December 15, 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.