Persius/hicric huggingface dataset:
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for anesthesia services (99100) provided on November 4, 2021. 
 
You asked the Plan to pay for anesthesia services. You say that the service at issue is not a bundled service. 
The Plan denied your request. The Plan says rules for payment have not been met. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
Per the Physician Fee Schedule, CPT code 99100 has a status indicator of B. This means that the payment for 
99100 is always bundled into the payment for another service or procedure Based on this information, we 
decided that Medicare rules for coverage of anesthesia services have not been met. Therefore, we decided that 
the Plan does not have to pay for anesthesia services (99100) provided on November 4, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the physician office visit (99205), provided on October 21, 
2021. 
 
You asked the Plan to pay for the physician office visit. You say that the service should be covered. The Plan 
denied your request. The Plan says you obtained this service from a provider who has opted out of 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 
physician office visit (99205), provided on October 21, 2021.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Ilumya. 
 
You asked the Plan to pre-approve Ilumya. You say that this is medically necessary. The Plan denied your 
request. The Plan says that you do not have any stated contraindications to the preferred products. 
 
Medicare covers Part B medications when they are reasonable and necessary but allows health plans to 
implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain Part B medications. 
 
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 Ilumya. Our reviewer says that Ilumya 
is not medically reasonable and necessary. You have plaque psoriasis. The requested medication is a new start.  
The provided records do not indicate that you have tried and failed the Plan's preferred step one alternative. The 
record does not indicate that you have a contraindication to or would have an adverse effect from the Plan's 
preferred step one alternative or provide an adequate medical rationale as to why the alternatives are not 
appropriate for you. Our physician reviewer found that your condition does not meet step therapy criteria for 
Ilumya. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Ilumya have not been met. Therefore, we decided that the Plan does not have to 
pre-approve Ilumya.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve additional home health visits. 
 
You asked the Plan to pre-approve additional home health visits. You say that the enrollee needs additional 
visits three times per week due to new wound care orders. The Plan denied your request. The Plan says the 
enrollee has already had 96 home health visits. The Plan has approved 9 visits to allow for transition and for the 
home health agency to complete paperwork. The enrollee's needs are met with the total of 105 approved visits. Additional visits are not medically necessary. The enrollee has had a lot of visits with no significant impact to 
the skilled service needs of the patient or improving the enrollee's outcome. 
 
The Plan must follow Medicare rules. The rules say that home health care services may be covered if it is 
medically necessary for the enrollee to receive skilled nursing or therapy. A doctor must certify the need for 
home health care services. 
 
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 additional home health visits. Our 
reviewer says that additional home health visits are not medically necessary. Our physician reviewer found the 
enrollee has reportedly been receiving home health skilled nursing services for wound care to a foot wound for 
eight months.  The provided documentation does not show measurable improvement.  As such, ongoing wound 
care via a home health skilled nursing is not medically necessary or reasonable. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of additional home health visits have not been met. Therefore, we decided that the 
Plan does not have to pre-approve additional home health visits.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a pneumatic compression device (E0675, E0673). 
 
You asked the Plan to pay for a pneumatic compression device. You say that the item is medically necessary. 
The Plan denied your request. The Plan says the pneumatic compression device is not covered by Medicare to 
prevent deep vein thrombosis during and/or following surgery. 
 
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, E0673).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the segmented pneumatic compression device (PCD) 
(E0651, E0668). 
 
 
 You asked the Plan to pre-approve the PCD. You say that you have a history of breast cancer, and the 
pneumatic compression device and appliance are medically necessary for treatment of chronic lymphedema per 
your doctors recommendation. The Plan denied your request. The Plan says the requested device is not 
medically necessary. 
 
The Plan follows Medicare rules. Medicare rules say that a PCD coded as E0651 is covered for both primary 
and secondary lymphedema in beneficiaries with chronic and severe lymphedema when the criteria listed in the 
Medicare rules section of this letter have been met. 
 
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 PCD. Our reviewer says that the 
LCD criteria have not been met in this case. Our physician reviewer found information from your physical 
therapy dated February 8, 2022. Your arm reduced from 43.2% to 25% and is well managed with a custom 
compression sleeve, hand is normal and does not require compression. There is improvement with conservative 
treatment. 
 
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 PCD have not been met. Therefore, we decided that the Plan does not have 
to pre-approve the segmented pneumatic compression device (PCD) (E0651, E0668).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the knee scooter, provided on September 17, 2021. 
 
You asked the Plan to pay for the knee scooter. You say that the item should be covered. The Plan denied your 
request. The Plan says you obtained this item through a provider who is not enrolled in Medicare. 
 
The Plan must follow Medicare rules. The rules say that Medicare payment cannot be made to a provider that is 
not enrolled in the Medicare program. 
 
Review of the file and Medicare records indicates that the provider at issue is not enrolled in the Medicare 
program. Therefore, we decided that the Plan does not have to pay for the knee scooter, provided on September 
17, 2021.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the critical care services (99291) provided on September 28, 
2021. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the billed service is not 
supported. 
 
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 99291 is "Critical care, evaluation and management of 
the critically ill or critically injured patient; first 30-74 minutes". 
 
We find that CPT code 99291 is not supported in the medical record. Specifically, the records do not show that 
30-74 minutes of critical care services were provided on the date of service in question. The records do not 
include the time spent providing these services. 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 the 
critical care services (99291) provided on September 28, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the services (84480, 84436, 84479) provided on August 24, 
2021. 
 You asked the Plan to pay for the services. The Plan denied your request. The Plan says these services are 
bundled. 
 
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 codes 
84436 and 84479 are column II codes to column I code 84439. We have also confirmed that code 84480 is a 
column II code to column I code 84481. This claim has not been billed with an appropriate modifier to bypass 
the edit. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we decided that 
the Plan does not have to pay for the services (84480, 84436, 84479) provided on August 24, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the cervical collar provided on September 8, 2021. 
 
You asked the Plan to pay for the cervical collar. You say that this enrollee required the medical equipment 
provided. The Plan denied your request. The Plan says there is insufficient documentation of a credible 
physical examination of the cervical spine. The Plan states there is no documentation of trauma to the neck, no 
documentation of a thorough neurologic and strength examination, and no documentation of imaging 
performed to evaluate the cervical spine. 
 
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 pay for the cervical collar. Our reviewer says that 
the requested collar not considered medically reasonable and necessary in this case. Our physician reviewer 
found the enrollee was evaluated by a provider on July 14, 2021.  Based on submitted documentation the reason for the appointment was for foot pain, all over pain, and pump 
medication refill. The member has implanted intrathecal Dilaudid pump for low back pain, bilateral hand, and 
right foot pain. Paracervical tenderness and cervical radiculopathy is noted, without mention of more detailed 
cervical examination. The review has determined that the items/services at issue in this case are medically 
reasonable or 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 the cervical collar have not been met. Therefore, we decided that the Plan does 
not have to pay for the cervical collar provided on September 8, 2021.
Appeal type: Inpatient Hospital
Decision: Partially Favorable

 
We decided that the Plan has to reduce the copayment for a hospital stay provided from December 31, 2021, to 
January 1, 2022. We also decided that the Plan does not have to fully waive the copayment for a hospital stay 
provided from December 31, 2021, to January 1, 2022. 
 
You asked the Plan to waive the copayment for a hospital stay. You say that you were not at any time in a 
semi-private room accommodation. You also say that you should not be responsible for the $298.63 
copayment. The Plan says that you have been charged the correct cost sharing amount. 
 
We decided that the Plan has to reduce the copayment for a hospital stay provided from December 31, 
2021, to January 1, 2022.  
 
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 did not provide medical records to confirm if you were admitted as an 
inpatient or if surgery took place on a different day from the emergency room visit. Without the medical 
records we are unable to determine if the inpatient hospital or the outpatient surgery copayments would apply. 
Therefore, we decided that the Plan has to reduce the copayment for a hospital stay provided from December 
31, 2021, to January 1, 2022. 
 
We also decided that the Plan does not have to fully waive the copayment for a hospital stay provided 
from December 31, 2021, to January 1, 2022. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information. Your 
contract with the Plan says that enrollees must pay a $90 copayment for an emergency room visit. 
 
The Plan says you must pay $298.63, which is less than a $390 copayment for a hospital stay. Based on the 
Plan contract, however, you cannot be asked to pay more than a $90 copayment for an emergency room visit. 
The EOC says that if your visit to the emergency room also includes outpatient hospital surgery, only your $90 
emergency care copayment applies. The case file shows you did receive emergency room services, and there is 
no evidence that your surgery was performed on a different day. Therefore, we decided that the Plan does not 
have to fully waive the copayment for a hospital stay provided from December 31, 2021, to January 1, 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: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for drug testing services provided to the enrollee on November 
11, 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 definitive confirmation testing was only necessary for two drug classes - oxycodone and opiates. 
 
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 pay for the services. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found the review has determined that it was not medically necessary to test for 22 or more drug classes in this 
case. 
 
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 pay for drug testing services provided to the enrollee on November 11, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the hearing aid, digital, binaural, behind the ear (V5261) 
provided March 19, 2021. 
 
You asked the Plan to pay for the hearing aids. You say that you tried the Plans covered hearing aids and they 
were inadequate for you needs. This hearing aid is necessary and should be covered. The Plan denied your 
request. The Plan says this type of hearing aid is not covered under your benefits. 
 
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 
Advanced or Premium hearing aids from the Plans specified hearing vendor network. 
 
We looked at the file and the Plan's rules. In this case the hearing aids purchased are not one of the Plans 
covered Advanced or Premium hearing aids. Additionally, the Plan provided documentation showing that you 
signed an Acknowledgement of Non-Covered Items and Services and Agreement to Proceed. Based on this 
information, we decided that these hearing aids are not covered under your benefits. Therefore, we decided that 
the Plan does not have to pay for the hearing aid, digital, binaural, behind the ear (V5261) provided March 19, 
2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for comprehensive eye exam (92004) 
refraction (92015) and scanning computerized ophthalmic diagnostic imaging (92134) provided December 7, 
2021. 
 
You asked the Plan to waive the copayment for the vision services. You say that you received a bill for $40. 
You would like to appeal this because you were under the impression this was just the routine eye exam and as 
a preventative annual service it should be a $0 copayment, per your Plan. The Plan denied your request. The 
Plan says the claim was processed with the correct cost share applied per the Evidence of Coverage. 
 
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 $40 copayment per visit for Medicare covered 
exams to treat diseases of the eye, including an annual glaucoma screening for members at high risk.  
 
You have been asked to pay $40 copayment for the vision services. The vision services fall within the Vision 
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 comprehensive eye exam 
(92004) refraction (92015) and scanning computerized ophthalmic diagnostic imaging (92134) provided 
December 7, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the radiofrequency ablation (RFA) of the sacroiliac (SI) joint 
provided on September 23, 2021. 
 
You asked the Plan to pay for RFA of the SI joint. You say that you would like this claim reprocessed and 
approved for payment. The Plan denied your request. The Plan says this service is considered 
experimental/investigational. 
 
The Plan must follow Medicare rules. Medicare rules say that RFA of SI joint is not medically 
necessary/investigational whether performed using traditional, cooled, or pulsed radiofrequency. Based on this 
information, we decided that Medicare rules for coverage of RFA of the SI joint have not been met. Therefore, 
we decided that the Plan does not have to pay for the radiofrequency ablation (RFA) of the sacroiliac (SI) joint 
provided on September 23, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a pneumatic compression device (E0652, E0667). 
 
You asked the Plan to pre-approve a pneumatic compression device. You say that the enrollee completed over 
four weeks of conservative therapy including compression though continues to have swelling of her abdominal 
region. You also say the enrollee went through a trial of the Flexitouch and had pre and post measurements of 
reduction in her ankle, calf, and thigh. The Plan denied your request. The Plan says there is no documentation 
of a four-week trial of daily, regular and multiple hour use of an E0650 or E0651 after careful, in person fitting, 
training, and supervision by a skilled technician. The Plan also says there are no documented measurements 
showing lack of improvement in the lymphedema extending into the chest, trunk, or abdomen. 
 
The Plan follows Medicare rules. The rules state that a PCD coded as E0652 is covered for the treatment of 
lymphedema extending onto the chest, trunk and/or abdomen after a four-week trial of conservative therapy 
demonstrating failed response to treatment with an E0650 or E0651. At least four weeks of regular, daily, 
multiple-hour home usage of the E0650 or E0651 is required. 
 
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, the record does not show that the enrollee had at least 
four weeks of regular, daily, multiple-hour home usage of the E0650 or E0651 after careful, in-person fitting, 
training and supervision by a technician who is skilled in and who regularly and successfully uses the appliance 
provided. Therefore, we decided that the Plan does not have to pre-approve a pneumatic compression device 
(E0652, E0667).