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

 
We decided that the Plan does not have to pay for a knee brace (L1851) and suspension sleeve (L2397), 
provided on October 22, 2021. 
 
You asked the Plan to pay for a knee brace and suspension sleeve. You say that the items should be covered. 
The Plan denied your request. The Plan says proof of delivery was not submitted. 
 
The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when there are both a 
physician order and proof of delivery.  
 
The record does not contain a valid proof of delivery for the supplies provided in this case. Specifically, no 
delivery slip was submitted. The record shows that the Plan made several attempts to obtain the necessary 
documentation without success. Therefore, we decided that the Plan does not have to pay for a knee brace 
(L1851) and suspension sleeve (L2397), provided on October 22, 2021.
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 needs LTACH level of care. 
The Plan denied your request. The Plan says the denial of authorization for LTACH care is correct. 
 
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 is receiving an appropriate level of care in the present acute care setting. 
When the enrollee is stable for discharge from the short-term acute care hospital the enrollee appears 
appropriate for care in a skilled nursing facility. Continued care in the present short-term acute care hospital is 
appropriate until the enrollee is stable for transfer to a lower level of care. 
 
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: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the FoundationOne testing provided on October 4, 2021. 
 
You asked the Plan to pay for the testing services. You say that the test is proven medically necessary. The 
Plan denied your request. The Plan says the panel is non-covered by Medicare. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We looked at the file, and Medicare rules. The testing procedure, submitted under CPT code 81455, are 
unlikely to impact therapeutic decision-making in the clinical management of the enrollee. Based on this 
information, we decided that Medicare rules for coverage of the testing have not been met. Therefore, we 
decided that the Plan does not have to pay for the FoundationOne testing provided on October 4, 2021.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Botox. 
 
You asked the Plan to pre-approve Botox. You say that the injection will aid in pain relief of abdominal muscle 
spasms. The Plan denied your request. The Plan says the clinical effectiveness of Botox for an incisional hernia 
have not been demonstrated. 
 
The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for FDA-
approved 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 Botox. Our physician reviewer found 
that the record indicates that the enrollee has a diagnosis of pain and muscle spasm from incisional hernia. The 
FDA has not stated that the requested drug is indicated for the enrollee's condition. The Medicare approved 
drug compendia do not contain a supportive citation for the use of the requested drug in the enrollee's clinical 
situation. The documentation does not support that the requested drug is safe and effective and otherwise 
reasonable and necessary for this enrollee. 
 
 We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Botox have not been met. Therefore, we decided that the Plan does not have to 
pre-approve Botox.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for 2D photographic images (D0350 x 5), comprehensive oral 
evaluation (D0150), bitewing x-rays (D0274), and fillings (D2330, D2391) provided on January 13, 2021. 
 
You asked the Plan to pay for the dental services. You say that you were never informed that your dentist was 
out of network. You say that you have gone to them for over 3 years. You also say that you do not feel 
responsible for this bill. The Plan denied your request. The Plan says the claim was not submitted within 12 
months of the date of service in this case. 
 
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 dental services was not filed until March 2, 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 2D photographic images (D0350 x 5), 
comprehensive oral evaluation (D0150), bitewing x-rays (D0274), and fillings (D2330, D2391) provided on 
January 13, 2021.
Appeal type: Drugs
Decision: Favorable

 
We decided that the Plan has to pre-approve pembrolizumab (Keytruda). 
 
You asked the Plan to pre-approve Keytruda. The Plan denied your request. The Plan says that the side effects 
will have serious impact on the quality of the enrollee's life without curing her cancer. 
 
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 Keytruda. Our physician reviewer 
found that The National Comprehensive Cancer Network has stated that the requested agent is a preferred 
second-line or subsequent therapy as a single agent if PD-L1 positive (combined positive score [CPS] =1) as 
determined by an FDA-approved test, or if microsatellite instability-high (MSI-H) or mismatch repair deficient 
(dMMR) tumors for local/regional recurrence and stage IVB or distant metastases. In this case, the record 
indicates that the enrollee has a diagnosis of metastatic cervical squamous cell carcinoma, PD-L positive as 
determined by an FDA approved test. The record indicates that the enrollee has regional lymph node 
recurrence. The enrollee has previously undergone radiation. The Medicare approved cancer drug 
compendium, National Comprehensive Cancer Network guidelines, contain a supportive citation for the use of 
the requested drug in the enrollee's clinical situation. The documentation does support that the requested drug is 
safe and effective and otherwise reasonable and necessary for this enrollee. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Keytruda have been met. Therefore, we decided that the Plan has to pre-approve 
pembrolizumab (Keytruda).  
 
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: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the non-emergency transportation: wheelchair van (A0130), 
and mileage (A0888) provided on November 29, 2021. 
 
You asked the Plan to pay for the transportation services. You say that the hospital arranged the transportation. 
You say that you did not know that this was not covered. You also say that you have already paid $275 
copayment for an ambulance. The Plan denied your request. The Plan says that transportation via wheelchair 
van is not covered by Medicare or the Plan. 
 
The Plan must follow Medicare rules. The rules say that Medicare does not pay for wheelchair van transport 
services.  
 
The services you have asked the Plan to pay for are wheelchair van transport services. Therefore, we decided 
that the Plan does not have to pay for the non-emergency transportation: wheelchair van (A0130), and mileage 
(A0888) provided on November 29, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a physician visit provided on June 22, 2021, by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for a physician visit. You say that it was the assisted living facilities responsibility to 
obtain prior authorization. The Plan denied your request. The Plan says care must be provided in the Plan's 
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 a physician visit provided on June 22, 2021, by an 
out-of-network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an adjustable socket system (BOA Click Socket) for a 
lower limb prosthesis. 
 
You asked the Plan to pre-approve adjustable socket system. You say that this is medically necessary due to the 
enrollee's struggles to maintain proper socket fit. The Plan denied your request. The Plan says the denial of 
authorization for this component is correct, because this is experimental/investigational. 
 
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 adjustable socket system. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found this adjustable socket system exceeds the enrollee's medical needs and is not proven 
to be safe and effective or Food & Drug Administration (FDA) approved.  
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of adjustable socket system have not been met. Therefore, we decided that the Plan 
does not have to pre-approve an adjustable socket system (BOA Click Socket) for a lower limb prosthesis.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the office visit (99204), provided on December 2, 2021. 
 
You asked the Plan to pay for the office visit. You say that the service should be covered. The Plan denied your 
request. The Plan says this is not a covered service. 
 
The Plan must follow Medicare rules. The rules say that the only chiropractic service Medicare covers is 
manual manipulation of the spine to correct a subluxation.  
 
The records show that the service at issue is not manual manipulation of the spine. Therefore, we decided that 
the Plan does not have to pay for the office visit (99204), provided on December 2, 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 the items should be covered. 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).
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ambulance service (A0998), provided on September 18, 
2021. 
 
You asked the Plan to pay for the ambulance service. You say that the service should be covered. The Plan 
denied your request. The Plan says this is not a covered service. 
 
The Plan must follow Medicare rules. The rules say that Medicare does not pay for ambulance services when 
there is no transport.  
 
The ambulance company did not provide transport services on September 18, 2021. The ambulance benefit is a 
transportation benefit. When there is no transport, neither Medicare nor the Plan pays for the services provided. 
Therefore, we decided that the Plan does not have to pay for the ambulance service (A0998), provided on 
September 18, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the extractions (D7210 x 6), simple extraction (D7140), fixed 
partial denture sectioning (D9120 x 2), and immediate upper denture (D5130) provided on January 12, 2022, 
by the out of network dentist. 
 
You asked the Plan to pay for the dental services. You say that you went to this dentist because of a referral 
from your sister. You say that you do not like seeing dentists. You say that you had a bad experience as a child. 
You also say that you need these services to be covered. The Plan denied your request. The Plan says the claim 
denied correctly. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the dental services you received are not among those covered under this benefit when you receive them out of network. Therefore, we decided that the 
Plan does not have to pay for the extractions (D7210 x 6), simple extraction (D7140), fixed partial denture 
sectioning (D9120 x 2), and immediate upper denture (D5130) provided on January 12, 2022, by the out of 
network dentist.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the office visit and laboratory work provided on April 27, 
2021, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for the office visit and the laboratory work. You say that you only saw the provider 
for two minutes to decide if you wanted to continue to see this provider. The Plan denied your request. The 
Plan says no prior authorization was 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 requested provider in this case is not a network provider with the Plan. The Plan had network providers 
available who could have provided the office visit and the laboratory work in this appeal. The Plan did not pre-
approve the office visit and the laboratory work. We found no exception that would require the Plan to pay for 
the office visit and the laboratory work. Therefore, we decided that the Plan does not have to pay for the office 
visit and laboratory work provided on April 27, 2021, by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the vision services provided on November 
2, 2021. 
 
You asked the Plan to waive the copayment for the vision services. You say that you are being overcharged. 
The Plan denied your request. The Plan says the cost share 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 a $35 
specialist copay for physician/practitioner services.  
 
You have been asked to pay a $35 specialist copay for the vision services. the vision services falls within the 
physician/practitioner services benefit category. Refractions are not covered unless it is for a routine eye exam. 
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 vision services provided on November 2, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the supplies and materials (99070) for chiropractic services, 
provided on January 15, 2021. 
 
You asked the Plan to pay for the supplies and materials. You say that the service should be covered. The Plan 
denied your request. The Plan says this is not a covered service. 
 
The Plan must follow Medicare rules. The rules say that the only chiropractic service Medicare covers is 
manual manipulation of the spine to correct a subluxation.  
 
The records show that the service at issue is not manual manipulation of the spine. Therefore, we decided that 
the Plan does not have to pay for the supplies and materials (99070) for chiropractic services, provided on 
January 15, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the eyeglass frames (V2020), provided on October 14, 2021. 
 
You asked the Plan to pay for the eyeglass frames. You say that the item should be covered. The Plan denied 
your request. The Plan says you have exhausted the Plan benefit for this item. 
 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 with up to a $200 allowance every two years toward the 
purchase of routine eyewear. 
 
We looked at the file and the Plan's rules. You have exhausted the Plan benefit for this service and are 
responsible for the difference. Based on this information, we decided that the Plan's rules for coverage of the 
eyeglass frames have not been met. Therefore, we decided that the Plan does not have to pay for the eyeglass 
frames (V2020), provided on October 14, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for telehealth services provided to the enrollee on August 19, 
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 service is included in the primary procedure, and the provider did not bill as required by 
Medicare coding regulations. 
 
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 99441 is "Telephone evaluation and management service 
by a physician or other qualified health care professional who may report evaluation and management services 
provided to an established patient, parent, or guardian not originating from a related E/M service provided 
within the previous 7 days nor leading to an E/M service or procedure within the next 24 hours or soonest 
available appointment; 5-10 minutes of medical discussion." 
 
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 there is no documentation that the 
denied code is supported. The telehealth services provided to the enrollee on August 19, 2021 were within 7 
days of the August 12, 2021 visit that was billed and paid.  
 
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 telehealth services provided to the enrollee on August 19, 2021.