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

 
We decided that the Plan does not have to pay for IV tubing extension set (S1015) infection control supplies 
above and beyond normal protocol (S8301) Additional supplies, materials, and clinical staff time over and 
above those usually included in an office visit or other non-facility service (99072) provided April 22, 2021. 
 
You asked the Plan to pay for the medical supplies. You say that these items you provided were not provided 
by the surgeon and are not available in the office setting like they might be at a hospital or ambulatory surgical 
care. The Plan denied your request. The Plan says codes S10156 and S8301 are invalid procedure codes and 
procedure code 99072 is denied as an unbundled service. 
 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 find that CPT codes S1015, S8301 and 99072 is not supported in the medical record. 
Specifically, procedure codes S1015 and S8301 are "S" codes which are assigned a status code "I" and are 
codes that are not valid for Medicare purposes. Code 99072 is assigned a status B code and is bundled in the 
payment for another service. Based on this information, we decided that Medicare rules for coverage of the 
medical supplies have not been met. Therefore, we decided that the Plan does not have to pay for IV tubing 
extension set (S1015) infection control supplies above and beyond normal protocol (S8301) Additional 
supplies, materials, and clinical staff time over and above those usually included in an office visit or other non-
facility service (99072) provided April 22, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services (87209) provided May 11, 2021. 
 
You asked the Plan to pay for the lab services. You say that the services were medically necessary. The Plan 
denied your request. The Plan says the documentation does 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. 
 
In this case, the CPT Code Manual definition of code 87209 is Smear, primary source with interpretation; 
complex special stain (eg, trichrome, iron hemotoxylin) for ova and parasites. 
 
 We find that CPT code 87209 is not supported in the medical record. Specifically, the laboratory report 
documents a blood smear, there is a more appropriate code to report for this procedure.  
Based on this information, we decided that Medicare rules for coverage of the lab services have not been met. 
Therefore, we decided that the Plan does not have to pay for lab services (87209) provided May 11, 2021.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve repetitive transcranial magnetic stimulation (90792). 
 
You asked the Plan to pre-approve repetitive transcranial magnetic stimulation. You say that you are appealing 
the denial of the request for second opinion for TMS services. The Plan denied your request. The Plan says the 
medical necessity for this request is not evident. 
 
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 repetitive transcranial magnetic 
stimulation. Our reviewer says that the requested items/services are not considered medically reasonable and 
necessary in this case. Our physician reviewer found the enrollee's diagnosis of major depressive disorder, 
recurrent episode, moderate in partial remission is not considered adequate for treatment with Repetitive 
Transcranial Magnetic Stimulation (rTMS). Utilizing the information from this enrollee that indicates this 
enrollee does have an indication for the requested Repetitive Transcranial Magnetic Stimulation (rTMS). This 
enrollee does not meet the criteria for Repetitive Transcranial Magnetic Stimulation (rTMS) therapy is 
considered medically necessary for this patient who suffers from Major Depressive Disorder. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of repetitive transcranial magnetic stimulation have not been met. Therefore, we 
decided that the Plan does not have to pre-approve repetitive transcranial magnetic stimulation (90792).
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pay for continuation of SNF services provided from March 14, 2021, 
through April 2, 2021. 
 
You asked the Plan to pay for continuation of SNF services. The Plan denied your request. The Plan says the 
enrollee's 100-day SNF benefit was exhausted on March 13, 2021. 
 
The Plan must follow Medicare rules. The rules say that enrollees are covered for up to 100 days of skilled care 
in a SNF in each benefit period. A benefit period begins on admission to a hospital or to SNF level of care and 
ends when the enrollee has gone 60 days in a row without inpatient hospital or SNF care.  
 
The file shows that the enrollee received 100 days of SNF care during the benefit period from 
November 6, 2020, through March 13, 2021. The Plan has covered 100 days of SNF care.  
 
Although the enrollee may still need skilled care, the Plan is not required to pay for more than 100 days of SNF 
coverage during this benefit period. The enrollee will be eligible for a new benefit period when the enrollee has 
not been receiving care in a hospital or skilled care in a SNF for at least 60 days in row. Therefore, we decided that the Plan does not have to pay for continuation of SNF services provided from March 14, 2021, through 
April 2, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for partial recoupment of inpatient hospital services provided 
from March 25, 2020, through March 27, 2020. 
 You asked the Plan to pay for partial recoupment of inpatient hospital services provided from March 25, 2020, 
through March 27, 2020. You say that the services were provided, and payment should be rendered. The Plan 
denied your request. The Plan says based on the documentation provided, coverage criteria has not been met. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report inpatient hospital services with the appropriate DRG, which is based, in part, on the 
reported principal and secondary diagnosis codes.   
 
In this case, you billed the inpatient services provided with DRG 854. 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 partial recoupment of inpatient hospital services provided from March 25, 2020, 
through March 27, 2020. Our reviewer says that the services are not medically necessary. Our physician 
reviewer found documentation submitted was reviewed and does not meet criteria. Sepsis is documented in the 
medical record, however, documentation does not clearly support sepsis, as documentation does not support 
evidence of life-threatening organ dysfunction due to underlying host. Documentation clearly supports care and 
treatment of cellulitis in the groin, and stay was extended due to decreased mobility. Therefore, sepsis cannot 
be verified.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided the 
medical records do not substantiate the DRG as billed. Therefore, we decided that the Plan does not have to pay 
for partial recoupment of inpatient hospital services provided from March 25, 2020, through March 27, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a battery back-up (A9270). 
 
You asked the Plan to pre-approve a battery back-up. You say that you are requesting the equipment as an 
exception because you do not have the money to pay for it. The Plan denied your request. The Plan says this 
item is not a covered benefit. 
 
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a 
medical purpose.  
 
The item 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. Therefore, we 
decided that the Plan does not have to pre-approve a battery back-up (A9270).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve vein surgery to be provided by an out-of-network 
(OON) provider. 
 
You asked the Plan to pre-approve surgical service. You say that you are appealing with supporting records. 
The Plan denied your request. The Plan says the denial of authorization for this service is correct, because this 
provider is out-of-network with the Plan and the enrollee can be treated within the Plan 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 pre-approve care from out-of-network providers only in cases involving 
emergencies, out of area urgent care and care that cannot be provided by network providers. 
 
The requested provider in this case is not a network provider with the Plan. The Plan has network providers 
available who can provide the items/services at issue in this appeal. We found no exception that would require 
the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve 
vein surgery to be provided by an out-of-network (OON) provider.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care. 
 
You asked the Plan to pre-approve SNF care. You say that you need therapy to get back to your baseline. The 
Plan denied your request. The Plan says the denial of authorization for SNF care is correct. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors 
listed in the Medicare rules section are met. Custodial care is 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 SNF care. Our reviewer says that daily 
skilled services are not necessary. Our physician reviewer found you do not have daily skilled nursing needs 
that require the specialized skill, knowledge, and judgment of a skilled professional nurse. You do not have 
daily skilled therapy needs that require the specialized skill, knowledge, and judgment of a skilled professional 
therapist. You do not require daily skilled nursing and/or skilled therapy on an inpatient basis in a skilled 
nursing facility (SNF) setting. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of SNF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve skilled nursing facility (SNF) care.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan has to pay for an office visit to be provided by an out-of-network provider. 
 
You asked the Plan to pay for an office visit. You say that you would like approval to see this doctor. The Plan 
denied your request. The Plan says that these services can be provided in-network. 
 
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 response for information that we received was a corrupt file; therefore, an 
unfavorable decision could not be made. Therefore, we decided that the Plan has to pay for an office visit to be 
provided by an out-of-network provider.  
 
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: Favorable

 
We decided that the Plan has to pay for the presumptive and definitive drug testing provided on May 14, 2021. 
 
You asked the Plan to pay for the drug testing. You say that these tests were ordered by the treating provider 
and are billed correctly. The Plan denied your request. The Plan says that the presumptive test is duplicative 
and has been performed by the same and/or different provider on the same date of service. The definitive 
testing code is not supported as 22 or more drug classes are not listed in the results. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. Services ordered by contract providers are also 
considered approved by the Plan.  
 
The presumptive drug testing was ordered in addition to the definitive testing by a contract provider. There is 
no Medicare rule which disallows payment for both presumptive and definitive tests on the same date of 
service. As such, the presumptive test is considered to be approved by the Plan. Code G0483, defined as 
definitive test of 22 or more drug classes is also supported by the records. The report clearly documents more 
than 22 drug class results as defined by the CPT manual. Based on this information, we decided that Medicare 
rules for coverage of the drug testing have been met. Therefore, we decided that the Plan has to pay for the 
presumptive and definitive drug testing provided on May 14, 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: Supplemental Benefit
Decision: Favorable

We decided that the Plan has to pay for the dental services provided on June 2, 2021. 
 
You asked the Plan to pay for the dental services. You say that you would like the Plan to reconsider their 
denial of payment. The Plan denied your request. The Plan says that the services are not covered. 
 
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. In this case, your appeal involves payment for dental services you received on 
June 2, 2021. However, the Plan only provided claim information and dental records for June 3, 2021. As the 
Plan has not provided any supporting evidence in the denial of your claim for the June 2, 2021 date of service, 
we find that the Plan has not substantiated their reasoning for denial of payment. Therefore, we decided that the 
Plan has to pay for the dental services provided on June 2, 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: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the comprehensive exam (D0150) provided on April 19, 
2021. 
 
You asked the Plan to pay for dental code D0150. You say that you would like the Plan to reconsider their 
denial of payment. The Plan denied your request. The Plan says the Plan paid for dental code D0150 for date of 
service February 27, 2019, which is less than three years ago. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plan's coverage rules apply in this case. 
 
We looked at the file, the Plan's contract and Medicare rules. The Plan's contract says that dental code D0150 is 
covered once every three plan years. The file shows that the Plan paid for dental code D0150 for date of service 
February 27, 2019, which is less than three years ago. Therefore, we decided that the Plan does not have to pay 
for the comprehensive exam (D0150) provided on April 19, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a pneumatic compression device (E0652) and segmental 
pneumatic appliance (E0667). 
 
You asked the Plan to pre-approve a pneumatic compression device and appliance. You say that you have tried 
all types of wraps in physical therapy, but nothing has gotten better over time. You were recently in the hospital 
for your legs swelling too much. The Plan denied your request. The Plan says the enrollee does not meet the 
LCD criteria for an advanced lymphedema pump as there is no failed four-week trial of a basic pneumatic 
compression device of either E0650 or E0651. 
 
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) and segmental pneumatic appliance (E0667).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a shower transfer bench. 
 
You asked the Plan to pre-approve a shower transfer bench. You say that a shower transfer bench is medically 
necessary. The Plan denied your request. The Plan says a shower transfer bench is not covered by Medicare. 
 
The Plan must follow Medicare rules. Medicare rules say that shower equipment is not covered because they 
are not primarily medical in nature. While a shower transfer bench may be appropriate in this case, neither the 
Plan nor Medicare offers coverage of this item. Therefore, we decided that the Plan does not have to pre-
approve a shower transfer bench.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a lightweight manual wheelchair (K0003, E1226). 
 
You asked the Plan to pre-approve the lightweight manual wheelchair. You say that the wheelchair is medically 
necessary. The Plan denied your request. The Plan says coverage criteria has not been met. 
 
The Plan follows Medicare rules. Medicare rules say that a lightweight wheelchair is only covered when a 
beneficiary can and does self-propel in a lightweight wheelchair. 
 
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 lightweight manual wheelchair. Our 
reviewer says that the requested wheelchair is not medically necessary. Our physician reviewer found there is 
no indication in the records that the enrollee is able to self-propel the wheelchair at issue. 
 
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 lightweight manual wheelchair have not been met. Therefore, we decided 
that the Plan does not have to pre-approve a lightweight manual wheelchair (K0003, E1226).
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for laboratory services (82310, 83970, 84100) provided on May 
4, 2021, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for laboratory services. You say that this should be covered. The Plan denied your 
request. The Plan says this was not 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 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 laboratory services (82310, 83970, 84100) 
provided on May 4, 2021, by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the non-covered chiropractic service (99204) provided on 
May 25, 2021. 
 
You asked the Plan to pay for code 99204. You say that you would like the Plan to reconsider their denial of 
payment. The Plan denied your request. The Plan says code 99204 is not payable when provided by a 
chiropractor. 
 
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, code 99204, is not manual manipulation of the spine. Therefore, we 
decided that the Plan does not have to pay for the non-covered chiropractic service (99204) provided on May 
25, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay $108 for contact lenses provided on July 1, 2021. 
 
You asked the Plan to pay for contact lenses. You say that you should still have the benefit for this purchase. 
The Plan denied your request. The Plan says you have exhausted the eyewear benefit; however, the Plan has 
reprocessed the claim for payment of $82 and the Plan is upholding the difference for payment of $108. 
 Medicare generally does not cover routine eyewear services. However, the Plan offers a routine eyewear 
benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case.  
 
We looked at the file and the Plan's rules. The file shows that the Plan covers a $250 allowance for 
supplemental eyewear every year. Therefore, we decided that the Plan does not have to pay $108 for contact 
lenses provided on July 1, 2021.