Persius/hicric huggingface dataset:
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 97010 billed for date of service November 
10, 2022. 
 
You asked the Plan to pay for procedure code 97010. You say that you had authorization on file for these 
services. The Plan denied your request. The Plan says procedure code 97010 is considered bundled and not 
separately payable. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate procedure code. 
 
We find that procedure code 97010 has a status indicator of B on the Physician Fee Schedule. This means that 
procedure code 97010 is not separately payable. Based on this information, we decided that Medicare rules for 
coverage of procedure code 97010 have not been met. Therefore, we decided that the Plan does not have to pay 
for procedure code 97010 billed for date of service November 10, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the hospital observation services provided 
by an in-network provider from September 22, 2022, to September 23, 2022. 
 
You asked the Plan to waive the copayment for the hospital observation services. You say that you do not agree 
with the copayment applied to these services. 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 $275 
copayment for each in-network Medicare-covered observation visit. 
 
You have been asked to pay a $275 copayment for the hospital observation services. These items/services fall 
within the outpatient hospital observation 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 hospital observation services provided by an in-network provider from September 22, 2022, to 
September 23, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a flex foot system (L5980) for a Freedom DynAdapt 
foot. 
 
You asked the Plan to pre-approve a flex foot system. You say that the enrollee has experienced asymmetrical 
residual limb atrophy changing the overall shape of their residual limb. You say that the enrollee's current 
prosthetic socket has been modified numerous times to tighten and accommodate for their previous limb 
atrophy and volume reduction no other modifications will achieve optimal fit. The Plan denied your request. 
The Plan says one of the parts for the requested foot exceeds the enrollee's medical need. The Plan also says 
that the code used is not approved to build the requested foot. 
 
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 L5980 is all lower extremity prostheses, flex foot 
system. 
 
We find that the HCPCS code L5980 is not supported in the medical records. Specifically, L5980 is not 
considered an approved code for the base foot unit that was approved in this case. Based on this information, 
we decided that Medicare rules for coverage of a flex foot system have not been met. Therefore, we decided 
that the Plan does not have to pre-approve a flex foot system (L5980) for a Freedom DynAdapt foot.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the implantable loop reader (ILR) (33285). 
 
You asked the Plan to pre-approve the ILR. You say that the device is necessary. The Plan denied your request. 
The Plan says ILR's are not needed for routine assessment of patients with atrial fibrillation. 
 
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 ILR. Our physician reviewer found 
while the enrollee has a history of premature ventricular contractions (PVCs), there is no documentation 
provided to suggest a history of unexplained syncope, cryptogenic stroke or any other apparent indication for 
an ILR. In summary, there is insufficient documentation to support the medical necessity for insertion of an 
ILR in this enrollee's clinical management. 
 
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 ILR have not been met. Therefore, we decided that the Plan does not have to 
pre-approve the implantable loop reader (ILR) (33285).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a right leg sclerotherapy (36471). 
 
You asked the Plan to pre-approve a right leg sclerotherapy. You say that the service is medically necessary. 
The Plan denied your request. The Plan says the service is not medically necessary. 
 
The Plan follows Medicare rules. Medicare rules say that the treatments to eliminate the saphenous vein reflux 
will be considered medically necessary if the patient remains symptomatic after a six-week trial of conservative 
therapy and has reflux in a saphenous vein. The treatments of the tributary veins will be considered medically 
necessary if saphenous reflux is not present or already successfully eliminated, the veins are greater than 4 mm 
in diameter and if the patient remains symptomatic after a six-week trial of conservative therapy. The 
components of the conservative therapy include, but are not limited to weight reduction, a daily exercise plan, 
periodic leg elevation, and the use of graduated compression stockings.  
 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 right leg sclerotherapy. Our reviewer 
says that the service is not medically necessary. Our physician reviewer found there is no indication the 
member has tried and failed conservative therapy. 
 
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 right leg sclerotherapy have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a right leg sclerotherapy (36471).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the frames, the tint, and the progressive lenses provided by 
Deo PR Retail on October 7, 2022. 
 
You asked the Plan to pay for the frames, the tint, and the progressive lenses provided by Deo PR Retail. You 
say that you are requesting reimbursement for the eyewear. The Plan denied your request. The Plan says the 
provider does not participate in Medicare. 
 
The Plan must follow Medicare rules. The rules say that no Medicare payment may be made to a beneficiary 
for items or services provided directly by a physician or practitioner who has opted out of the program except 
in cases involving emergencies or urgently needed care. 
 
The services at issue in this appeal were provided in a non-urgent, non-emergent situation by the provider who 
has opted out of the Medicare program. Therefore, we decided that the Plan does not have to pay for the 
frames, the tint, and the progressive lenses provided by Deo PR Retail on October 7, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a computed tomography, thorax, low dose for lung 
cancer screening, without contrast material(s) (71271). 
 You asked the Plan to pre-approve a CT scan of the chest. You say that the requested lung cancer screening is 
medically necessary for the enrollee. The Plan denied your request. The Plan says the enrollee does not meet 
criteria for approval of the requested lung cancer screening CT scan. 
 
The Plan must follow Medicare rules. Medicare rules say that CT scans are covered only when they are 
medically necessary.  
 
We looked at the file and Medicare rules. Medicare states to be eligible for a lung cancer screening with LDCT, 
the enrollee must be between the ages of 50 to 77 years old. The records show that the enrollee is 79 years old, 
therefore, the service is not covered. Based on this information, we decided that Medicare rules for coverage of 
a CT scan of the chest have not been met. Therefore, we decided that the Plan does not have to pre-approve a 
computed tomography, thorax, low dose for lung cancer screening, without contrast material(s) (71271).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the single vision lens and the frames provided on 
October 26, 2022. 
 You asked the Plan to pre-approve the single vision lens and the frames. You say that you went to the out-of-
network provider because their prices were lower than the in-network options. The Plan denied your request. 
The Plan says the provider was out-of-network. 
 
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 these services when received by a network provider. 
 
We looked at the file and the Plan's rules. Specifically, the provider was out-of-network. Based on this 
information, we decided that the Plan's rules for coverage of the single vision lens and the frames have not been 
met. Therefore, we decided that the Plan does not have to pre-approve the single vision lens and the frames 
provided on October 26, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the standard frames and the polycarbonate lens provided 
on July 26, 2022. 
 
You asked the Plan to pre-approve the standard frames and the polycarbonate lens. You say that you do not 
agree with the denial, and you want the Plan to reconsider the payment. The Plan denied your request. The Plan 
says the provider was out-of-network.  
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 these services when provided by network providers. 
 
We looked at the file and the Plan's rules. Specifically, the provider was out-of-network. Based on this 
information, we decided that the Plan's rules for coverage of the standard frames and the polycarbonate lens 
have not been met. Therefore, we decided that the Plan does not have to pre-approve the standard frames and 
the polycarbonate lens provided on July 26, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the hospital outpatient clinic visit for assessment and 
management of a patient (G0463) provided on September 15, 2022, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for the outpatient clinic visit. You say that you would like a retro-authorization as 
the service was medically necessary. The Plan denied your request. The Plan says prior authorization was not 
obtained. 
 
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 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 hospital outpatient clinic visit for assessment and 
management of a patient (G0463) provided on September 15, 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 enrollee meets LTACH admission 
criteria, and their ongoing medical needs warrant an LTACH level of care of achieve a safe and sustainable 
discharge. The Plan denied your request. The Plan says the enrollee does not meet Medicare guidelines for an 
LTACH admission. 
 
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 that all medically necessary care is being provided in the current acute care setting.  
There are no services available at the LTACH that the enrollee requires that are not available at the health care 
setting being offered by the Plan. The Plan has approved ongoing care in the current acute care setting. The 
requested LTACH services are not medically necessary, reasonable, and appropriate for the diagnosis and 
condition of the enrollee and able to be furnished safely and effectively only on an inpatient basis. 
 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 LTACH services.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the oncology services provided on April 25, 2022, by an out-
of-network (OON) provider. 
 
You asked the Plan to pay for the oncology services. You say that you believe these services are appropriate 
based on the enrollee's past medical history. The Plan denied your request. The Plan says services from non-
participating providers are not covered under open access unless pre-authorized. 
 
 
 Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The requested provider in this case is not a network provider with the Plan. The Plan did not pre-approve the 
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 oncology services provided on April 25, 2022, 
by an out-of-network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the flexible protective outer surface covering system (L5964) 
provided on June 8, 2022. 
 
You asked the Plan to pay for the flexible protective outer surface covering system. You say that the protective 
cover would not be placed on the device for several weeks due to pending possible adjustments on the 
prosthetic device. You also say that you would like the information to be reviewed for provider reimbursement. 
The Plan denied your request. The Plan says the enrollee does not meet criteria for a need for protection against 
unusually harsh environment situations. 
 
The Plan must follow Medicare rules. Medicare rules say that protective outer surface covering systems are not 
for cosmetic or convenience reasons, or for everyday usage in a typical environment. 
 
 
 We looked at the file and Medicare rules. Specifically, the record shows that the enrollee wanted this item to 
protect their prosthesis from rainy weather. Based on this information, we decided that Medicare rules for 
coverage of the flexible protective outer surface covering system have not been met. Therefore, we decided that 
the Plan does not have to pay for the flexible protective outer surface covering system (L5964) provided on 
June 8, 2022.
Appeal type: DME/ Orthotics
Decision: Favorable

 
We decided that the Plan has to pay for the oxygen concentrator (E1390), portable gaseous oxygen system 
(E0431), and nebulizer (E0570) provided on September 16, 2022. 
 
You asked the Plan to pay for the oxygen concentrator, portable gaseous oxygen system, and nebulizer. You 
say that the enrollee had prior authorization for the codes billed. The Plan denied your request. The Plan says 
that services from non-participating providers are not covered under the Plan unless pre-authorized. 
 
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 records do not support that these items were not authorized. This means that 
the Plan has not provided a valid reason for denying payment of the oxygen concentrator, portable gaseous 
oxygen system, and nebulizer. Specifically, within the records provided there is an authorization showing these 
items were approved and valid from May 6, 2022, to November 13, 2022. This timeframe includes this 
September 16, 2022, date of service which is at appeal. It is the burden of the Health Plan to substantiate their 
denial with evidence. 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 the oxygen concentrator (E1390), portable gaseous oxygen 
system (E0431), and nebulizer (E0570) provided on September 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: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the echocardiogram (93005) and hospital observation, per 
hour (G0378) provided on March 29, 2021. 
 
You asked the Plan to pay for the outpatient hospital care. You say that this claim was denied in error. The Plan 
denied your request. The Plan says the claim was not filed timely. 
 
The Plan follows Medicare rules. The rules say that claims for services furnished on or after January 1, 2010, 
must be filed no later than one calendar year after the date of service. 
 
The record shows that a claim for the outpatient hospital care was not filed until September 9, 2022. This 
means that more than one calendar year from the date of service had passed before a claim was filed. 
Therefore, we decided that the Plan does not have to pay for the echocardiogram (93005) and hospital 
observation, per hour (G0378) provided on March 29, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the facedown recovery system provided on September 26, 
2022, by a provider that does not participate in Medicare. 
 
You asked the Plan to pay for facedown recovery system. You say that when you contacted the Plan prior to 
your surgery, you were advised that 80% of the cost would be covered, and that prior authorization would not 
be needed. The Plan denied your request. The Plan says you rented this durable medical equipment (DME) 
from a provider that does not accept Medicare. The Plan also says that you were advised by your surgeon's 
office to contact your insurance to get confirmation for the item because they believed it was not covered by 
Medicare. 
 
The Plan must follow Medicare rules. Medicare rules say that to receive payment for covered Medicare items 
or services, a provider or supplier must be enrolled in the Medicare program. 
 
 
 
 We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of facedown recovery system have not been met. The provider you rented this item from is not part of 
the Medicare program and is not payable. The record shows that you were advised by a Plan representative 
when you contacted the Plan on September 12, 2022, that equipment is normally covered under DME 20% 
coinsurance, but the specific item you requested was not on the list. Therefore, we decided that the Plan does 
not have to pay for the facedown recovery system provided on September 26, 2022, by a provider that does not 
participate in Medicare.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the automatic external defibrillator (AED) (K0606) provided 
on October 6, 2021. 
 
You asked the Plan to pay for the AED. You say that the device in this case is medically necessary. You also 
say that the submitted claim should be allowed for payment. The Plan denied your request. The Plan says the 
original claim submission must be filed within 1 calendar year after services rendered. The Plan also says that 
the claim was not filed timely. 
 
The Plan follows Medicare rules. The rules say that claims for services furnished on or after January 1, 2010, 
must be filed no later than one calendar year after the date of service. 
 
The record shows that a claim for the AED was not filed until November 7, 2022. This means that more than 
one calendar year from the date of service had passed before a claim was filed. Therefore, we decided that the 
Plan does not have to pay for the automatic external defibrillator (AED) (K0606) provided on October 6, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the human papilloma virus (HPV) vaccine (90651), and the 
administration (90472) provided on October 19, 2022. 
 
You asked the Plan to pay for the vaccine services. You say that you got the vaccine according to your doctor. 
You also say that you were not aware that the HPV vaccine was not covered under your plan. The Plan denied 
your request. The Plan says the vaccine at issue in this case is not covered under Medicare Part B. 
 
In the absence of injury or direct exposure to illness, Medicare does not pay for or provide the vaccine services. 
The Plan follows the same rules.  
 
Records do not show that you have been injured or directly exposed to any illness related to the vaccine 
services. Therefore, we decided that the Plan does not have to pay for the human papilloma virus (HPV) 
vaccine (90651), and the administration (90472) provided on October 19, 2022.  
 
Benefits for the vaccine services may be available under Medicare Part D. Contact the Plan that administers 
Part D benefits for further information concerning any benefits and appeal rights.